2017 QHP Landscape SHOP Market Dental

State Code Want total control? Request access to start using the data.	Fips County Code Want total control? Request access to start using the data.	County Name Want total control? Request access to start using the data.	Metal Level Want total control? Request access to start using the data.	Issuer Name Want total control? Request access to start using the data.	Hios Issuer Id Want total control? Request access to start using the data.	Plan Id (Standard Component) Want total control? Request access to start using the data.	Plan Marketing Name Want total control? Request access to start using the data.	Plan Type Want total control? Request access to start using the data.	Rating Area Want total control? Request access to start using the data.	Child Only Offering Want total control? Request access to start using the data.	Source Want total control? Request access to start using the data.	Customer Service Phone Number Local Want total control? Request access to start using the data.	Customer Service Phone Number Toll Free Want total control? Request access to start using the data.	Customer Service Phone Number Tty Want total control? Request access to start using the data.	Network Url Want total control? Request access to start using the data.	Plan Brochure Url Want total control? Request access to start using the data.	Routine Dental Services - Adult (Coverage) Want total control? Request access to start using the data.	Basic Dental Care - Adult (Coverage) Want total control? Request access to start using the data.	Major Dental Care - Adult (Coverage) Want total control? Request access to start using the data.	Dental Check-Up For Children (Coverage) Want total control? Request access to start using the data.	Basic Dental Care - Child (Coverage) Want total control? Request access to start using the data.	Major Dental Care - Child (Coverage) Want total control? Request access to start using the data.	Orthodontia - Child (Coverage) Want total control? Request access to start using the data.	Premium Child Want total control? Request access to start using the data.	Premium Adult Individual Age 21 Want total control? Request access to start using the data.	Premium Adult Individual Age 27 Want total control? Request access to start using the data.	Premium Adult Individual Age 30 Want total control? Request access to start using the data.	Premium Adult Individual Age 40 Want total control? Request access to start using the data.	Premium Adult Individual Age 50 Want total control? Request access to start using the data.	Premium Adult Individual Age 60 Want total control? Request access to start using the data.	Premium Couple 21 Want total control? Request access to start using the data.	Premium Couple 30 Want total control? Request access to start using the data.	Premium Couple 40 Want total control? Request access to start using the data.	Premium Couple 50 Want total control? Request access to start using the data.	Premium Couple 60 Want total control? Request access to start using the data.	Couple+1 Child, Age 21 Want total control? Request access to start using the data.	Couple+1 Child, Age 30 Want total control? Request access to start using the data.	Couple+1 Child, Age 40 Want total control? Request access to start using the data.	Couple+1 Child, Age 50 Want total control? Request access to start using the data.	Couple+2 Children, Age 21 Want total control? Request access to start using the data.	Couple+2 Children, Age 30 Want total control? Request access to start using the data.	Couple+2 Children, Age 40 Want total control? Request access to start using the data.	Couple+2 Children, Age 50 Want total control? Request access to start using the data.	Couple+3 Or More Children, Age 21 Want total control? Request access to start using the data.	Couple+3 Or More Children, Age 30 Want total control? Request access to start using the data.	Couple+3 Or More Children, Age 40 Want total control? Request access to start using the data.	Couple+3 Or More Children, Age 50 Want total control? Request access to start using the data.	Individual+1 Child, Age 21 Want total control? Request access to start using the data.	Individual+1 Child, Age 30 Want total control? Request access to start using the data.	Individual+1 Child, Age 40 Want total control? Request access to start using the data.	Individual+1 Child, Age 50 Want total control? Request access to start using the data.	Individual+2 Children, Age 21 Want total control? Request access to start using the data.	Individual+2 Children, Age 30 Want total control? Request access to start using the data.	Individual+2 Children, Age 40 Want total control? Request access to start using the data.	Individual+2 Children, Age 50 Want total control? Request access to start using the data.	Individual+3 Or More Children, Age 21 Want total control? Request access to start using the data.	Individual+3 Or More Children, Age 30 Want total control? Request access to start using the data.	Individual+3 Or More Children, Age 40 Want total control? Request access to start using the data.	Individual+3 Or More Children, Age 50 Want total control? Request access to start using the data.	Dental Deductible - Individual - Standard Want total control? Request access to start using the data.	Dental Deductible - Family - Standard Want total control? Request access to start using the data.	Dental Deductible - Family (Per Person) - Standard Want total control? Request access to start using the data.	Dental Maximum Out Of Pocket - Individual - Standard Want total control? Request access to start using the data.	Dental Maximum Out Of Pocket - Family - Standard Want total control? Request access to start using the data.	Dental Maximum Out Of Pocket - Family (Per Person) - Standard Want total control? Request access to start using the data.	Routine Dental Services - Adult Want total control? Request access to start using the data.	Basic Dental Care - Adult Want total control? Request access to start using the data.	Major Dental Care - Adult Want total control? Request access to start using the data.	Orthodontia - Adult Want total control? Request access to start using the data.	Dental Check-Up For Children Want total control? Request access to start using the data.	Basic Dental Care - Child Want total control? Request access to start using the data.	Major Dental Care - Child Want total control? Request access to start using the data.	Orthodontia - Child Want total control? Request access to start using the data.
AK	02013	Aleutians East	Low	BEST Life and Health Insurance Company	74819	74819AK0010009	BESTDental Standard - L	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	49.04	52.39	52.39	52.39	52.39	52.39	98.08	104.78	104.78	104.78	104.78	136.25	142.95	142.95	142.95	174.42	181.12	181.12	181.12	212.59	219.29	219.29	219.29	87.21	90.56	90.56	90.56	125.38	128.73	128.73	128.73	163.55	166.9	166.9	166.9	75	See Plan Brochure	75	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02013	Aleutians East	Low	BEST Life and Health Insurance Company	74819	74819AK0010011	BESTDental Choice - L	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	46.14	49.29	49.29	49.29	49.29	49.29	92.28	98.58	98.58	98.58	98.58	130.45	136.75	136.75	136.75	168.62	174.92	174.92	174.92	206.79	213.09	213.09	213.09	84.31	87.46	87.46	87.46	122.48	125.63	125.63	125.63	160.65	163.8	163.8	163.8	75	See Plan Brochure	75	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02013	Aleutians East	Low	BEST Life and Health Insurance Company	74819	74819AK0010012	BESTDental Value	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	32.03	34.21	34.21	34.21	34.21	34.21	64.06	68.42	68.42	68.42	68.42	102.23	106.59	106.59	106.59	140.4	144.76	144.76	144.76	178.57	182.93	182.93	182.93	70.2	72.38	72.38	72.38	108.37	110.55	110.55	110.55	146.54	148.72	148.72	148.72	75	See Plan Brochure	75	350	700	350	No Charge	40% Coinsurance after deductible	60% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02016	Aleutians West	High	Oregon Dental Service	21989	21989AK0090001	Delta Dental Premier Practical Plan 1000	Indemnity	Rating Area 2	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf	X	X	X	X	X	X	X	64	58	58	58	58	58	58	116	116	116	116	116	180	180	180	180	244	244	244	244	308	308	308	308	122	122	122	122	186	186	186	186	250	250	250	250	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02016	Aleutians West	High	Oregon Dental Service	21989	21989AK0090002	Delta Dental Premier Practical Plan 1500	Indemnity	Rating Area 2	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf	X	X	X	X	X	X	X	74	67	67	67	67	67	67	134	134	134	134	134	208	208	208	208	282	282	282	282	356	356	356	356	141	141	141	141	215	215	215	215	289	289	289	289	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02016	Aleutians West	Low	BEST Life and Health Insurance Company	74819	74819AK0010009	BESTDental Standard - L	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	49.04	52.39	52.39	52.39	52.39	52.39	98.08	104.78	104.78	104.78	104.78	136.25	142.95	142.95	142.95	174.42	181.12	181.12	181.12	212.59	219.29	219.29	219.29	87.21	90.56	90.56	90.56	125.38	128.73	128.73	128.73	163.55	166.9	166.9	166.9	75	See Plan Brochure	75	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02016	Aleutians West	Low	BEST Life and Health Insurance Company	74819	74819AK0010011	BESTDental Choice - L	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	46.14	49.29	49.29	49.29	49.29	49.29	92.28	98.58	98.58	98.58	98.58	130.45	136.75	136.75	136.75	168.62	174.92	174.92	174.92	206.79	213.09	213.09	213.09	84.31	87.46	87.46	87.46	122.48	125.63	125.63	125.63	160.65	163.8	163.8	163.8	75	See Plan Brochure	75	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02016	Aleutians West	Low	BEST Life and Health Insurance Company	74819	74819AK0010012	BESTDental Value	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	32.03	34.21	34.21	34.21	34.21	34.21	64.06	68.42	68.42	68.42	68.42	102.23	106.59	106.59	106.59	140.4	144.76	144.76	144.76	178.57	182.93	182.93	182.93	70.2	72.38	72.38	72.38	108.37	110.55	110.55	110.55	146.54	148.72	148.72	148.72	75	See Plan Brochure	75	350	700	350	No Charge	40% Coinsurance after deductible	60% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02020	Anchorage	High	BEST Life and Health Insurance Company	74819	74819AK0010007	BESTDental Premium	PPO	Rating Area 1	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	49.3	54.94	58.7	58.7	58.7	58.7	58.7	109.88	117.4	117.4	117.4	117.4	159.18	166.7	166.7	166.7	208.48	216	216	216	257.78	265.3	265.3	265.3	104.24	108	108	108	153.54	157.3	157.3	157.3	202.84	206.6	206.6	206.6	50	See Plan Brochure	50	350	700	350	No Charge	10% Coinsurance after deductible	40% Coinsurance after deductible	Not Covered	No Charge	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02020	Anchorage	High	BEST Life and Health Insurance Company	74819	74819AK0010008	BESTDental Standard - H	PPO	Rating Area 1	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	49.3	49.04	52.39	52.39	52.39	52.39	52.39	98.08	104.78	104.78	104.78	104.78	147.38	154.08	154.08	154.08	196.68	203.38	203.38	203.38	245.98	252.68	252.68	252.68	98.34	101.69	101.69	101.69	147.64	150.99	150.99	150.99	196.94	200.29	200.29	200.29	50	See Plan Brochure	50	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02020	Anchorage	High	BEST Life and Health Insurance Company	74819	74819AK0010010	BESTDental Choice - H	PPO	Rating Area 1	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	49.3	46.14	49.29	49.29	49.29	49.29	49.29	92.28	98.58	98.58	98.58	98.58	141.58	147.88	147.88	147.88	190.88	197.18	197.18	197.18	240.18	246.48	246.48	246.48	95.44	98.59	98.59	98.59	144.74	147.89	147.89	147.89	194.04	197.19	197.19	197.19	50	See Plan Brochure	50	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02020	Anchorage	High	Oregon Dental Service	21989	21989AK0090001	Delta Dental Premier Practical Plan 1000	Indemnity	Rating Area 1	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf	X	X	X	X	X	X	X	64	58	58	58	58	58	58	116	116	116	116	116	180	180	180	180	244	244	244	244	308	308	308	308	122	122	122	122	186	186	186	186	250	250	250	250	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02020	Anchorage	High	Oregon Dental Service	21989	21989AK0090002	Delta Dental Premier Practical Plan 1500	Indemnity	Rating Area 1	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf	X	X	X	X	X	X	X	74	67	67	67	67	67	67	134	134	134	134	134	208	208	208	208	282	282	282	282	356	356	356	356	141	141	141	141	215	215	215	215	289	289	289	289	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02050	Bethel	High	Oregon Dental Service	21989	21989AK0090001	Delta Dental Premier Practical Plan 1000	Indemnity	Rating Area 1	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf	X	X	X	X	X	X	X	64	58	58	58	58	58	58	116	116	116	116	116	180	180	180	180	244	244	244	244	308	308	308	308	122	122	122	122	186	186	186	186	250	250	250	250	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02050	Bethel	High	Oregon Dental Service	21989	21989AK0090002	Delta Dental Premier Practical Plan 1500	Indemnity	Rating Area 1	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf	X	X	X	X	X	X	X	74	67	67	67	67	67	67	134	134	134	134	134	208	208	208	208	282	282	282	282	356	356	356	356	141	141	141	141	215	215	215	215	289	289	289	289	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02050	Bethel	Low	BEST Life and Health Insurance Company	74819	74819AK0010009	BESTDental Standard - L	PPO	Rating Area 1	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	49.04	52.39	52.39	52.39	52.39	52.39	98.08	104.78	104.78	104.78	104.78	136.25	142.95	142.95	142.95	174.42	181.12	181.12	181.12	212.59	219.29	219.29	219.29	87.21	90.56	90.56	90.56	125.38	128.73	128.73	128.73	163.55	166.9	166.9	166.9	75	See Plan Brochure	75	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02050	Bethel	Low	BEST Life and Health Insurance Company	74819	74819AK0010011	BESTDental Choice - L	PPO	Rating Area 1	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	46.14	49.29	49.29	49.29	49.29	49.29	92.28	98.58	98.58	98.58	98.58	130.45	136.75	136.75	136.75	168.62	174.92	174.92	174.92	206.79	213.09	213.09	213.09	84.31	87.46	87.46	87.46	122.48	125.63	125.63	125.63	160.65	163.8	163.8	163.8	75	See Plan Brochure	75	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02050	Bethel	Low	BEST Life and Health Insurance Company	74819	74819AK0010012	BESTDental Value	PPO	Rating Area 1	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	32.03	34.21	34.21	34.21	34.21	34.21	64.06	68.42	68.42	68.42	68.42	102.23	106.59	106.59	106.59	140.4	144.76	144.76	144.76	178.57	182.93	182.93	182.93	70.2	72.38	72.38	72.38	108.37	110.55	110.55	110.55	146.54	148.72	148.72	148.72	75	See Plan Brochure	75	350	700	350	No Charge	40% Coinsurance after deductible	60% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02060	Bristol Bay	Low	BEST Life and Health Insurance Company	74819	74819AK0010009	BESTDental Standard - L	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	49.04	52.39	52.39	52.39	52.39	52.39	98.08	104.78	104.78	104.78	104.78	136.25	142.95	142.95	142.95	174.42	181.12	181.12	181.12	212.59	219.29	219.29	219.29	87.21	90.56	90.56	90.56	125.38	128.73	128.73	128.73	163.55	166.9	166.9	166.9	75	See Plan Brochure	75	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02060	Bristol Bay	Low	BEST Life and Health Insurance Company	74819	74819AK0010011	BESTDental Choice - L	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	46.14	49.29	49.29	49.29	49.29	49.29	92.28	98.58	98.58	98.58	98.58	130.45	136.75	136.75	136.75	168.62	174.92	174.92	174.92	206.79	213.09	213.09	213.09	84.31	87.46	87.46	87.46	122.48	125.63	125.63	125.63	160.65	163.8	163.8	163.8	75	See Plan Brochure	75	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02060	Bristol Bay	Low	BEST Life and Health Insurance Company	74819	74819AK0010012	BESTDental Value	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	32.03	34.21	34.21	34.21	34.21	34.21	64.06	68.42	68.42	68.42	68.42	102.23	106.59	106.59	106.59	140.4	144.76	144.76	144.76	178.57	182.93	182.93	182.93	70.2	72.38	72.38	72.38	108.37	110.55	110.55	110.55	146.54	148.72	148.72	148.72	75	See Plan Brochure	75	350	700	350	No Charge	40% Coinsurance after deductible	60% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02068	Denali	High	Oregon Dental Service	21989	21989AK0090001	Delta Dental Premier Practical Plan 1000	Indemnity	Rating Area 2	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf	X	X	X	X	X	X	X	64	58	58	58	58	58	58	116	116	116	116	116	180	180	180	180	244	244	244	244	308	308	308	308	122	122	122	122	186	186	186	186	250	250	250	250	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02068	Denali	High	Oregon Dental Service	21989	21989AK0090002	Delta Dental Premier Practical Plan 1500	Indemnity	Rating Area 2	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf	X	X	X	X	X	X	X	74	67	67	67	67	67	67	134	134	134	134	134	208	208	208	208	282	282	282	282	356	356	356	356	141	141	141	141	215	215	215	215	289	289	289	289	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02090	Fairbanks North Star	High	Oregon Dental Service	21989	21989AK0090001	Delta Dental Premier Practical Plan 1000	Indemnity	Rating Area 2	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf	X	X	X	X	X	X	X	64	58	58	58	58	58	58	116	116	116	116	116	180	180	180	180	244	244	244	244	308	308	308	308	122	122	122	122	186	186	186	186	250	250	250	250	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02090	Fairbanks North Star	High	Oregon Dental Service	21989	21989AK0090002	Delta Dental Premier Practical Plan 1500	Indemnity	Rating Area 2	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf	X	X	X	X	X	X	X	74	67	67	67	67	67	67	134	134	134	134	134	208	208	208	208	282	282	282	282	356	356	356	356	141	141	141	141	215	215	215	215	289	289	289	289	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02090	Fairbanks North Star	Low	BEST Life and Health Insurance Company	74819	74819AK0010009	BESTDental Standard - L	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	49.04	52.39	52.39	52.39	52.39	52.39	98.08	104.78	104.78	104.78	104.78	136.25	142.95	142.95	142.95	174.42	181.12	181.12	181.12	212.59	219.29	219.29	219.29	87.21	90.56	90.56	90.56	125.38	128.73	128.73	128.73	163.55	166.9	166.9	166.9	75	See Plan Brochure	75	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02090	Fairbanks North Star	Low	BEST Life and Health Insurance Company	74819	74819AK0010011	BESTDental Choice - L	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	46.14	49.29	49.29	49.29	49.29	49.29	92.28	98.58	98.58	98.58	98.58	130.45	136.75	136.75	136.75	168.62	174.92	174.92	174.92	206.79	213.09	213.09	213.09	84.31	87.46	87.46	87.46	122.48	125.63	125.63	125.63	160.65	163.8	163.8	163.8	75	See Plan Brochure	75	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02090	Fairbanks North Star	Low	BEST Life and Health Insurance Company	74819	74819AK0010012	BESTDental Value	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	32.03	34.21	34.21	34.21	34.21	34.21	64.06	68.42	68.42	68.42	68.42	102.23	106.59	106.59	106.59	140.4	144.76	144.76	144.76	178.57	182.93	182.93	182.93	70.2	72.38	72.38	72.38	108.37	110.55	110.55	110.55	146.54	148.72	148.72	148.72	75	See Plan Brochure	75	350	700	350	No Charge	40% Coinsurance after deductible	60% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02105	Hoonah Angoon	Low	BEST Life and Health Insurance Company	74819	74819AK0010009	BESTDental Standard - L	PPO	Rating Area 3	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	37.49	48.16	51.46	51.46	51.46	51.46	51.46	96.32	102.92	102.92	102.92	102.92	133.81	140.41	140.41	140.41	171.3	177.9	177.9	177.9	208.79	215.39	215.39	215.39	85.65	88.95	88.95	88.95	123.14	126.44	126.44	126.44	160.63	163.93	163.93	163.93	75	See Plan Brochure	75	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02105	Hoonah Angoon	Low	BEST Life and Health Insurance Company	74819	74819AK0010011	BESTDental Choice - L	PPO	Rating Area 3	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	37.49	45.32	48.41	48.41	48.41	48.41	48.41	90.64	96.82	96.82	96.82	96.82	128.13	134.31	134.31	134.31	165.62	171.8	171.8	171.8	203.11	209.29	209.29	209.29	82.81	85.9	85.9	85.9	120.3	123.39	123.39	123.39	157.79	160.88	160.88	160.88	75	See Plan Brochure	75	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02105	Hoonah Angoon	Low	BEST Life and Health Insurance Company	74819	74819AK0010012	BESTDental Value	PPO	Rating Area 3	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	37.49	31.46	33.6	33.6	33.6	33.6	33.6	62.92	67.2	67.2	67.2	67.2	100.41	104.69	104.69	104.69	137.9	142.18	142.18	142.18	175.39	179.67	179.67	179.67	68.95	71.09	71.09	71.09	106.44	108.58	108.58	108.58	143.93	146.07	146.07	146.07	75	See Plan Brochure	75	350	700	350	No Charge	40% Coinsurance after deductible	60% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02110	Juneau	High	BEST Life and Health Insurance Company	74819	74819AK0010007	BESTDental Premium	PPO	Rating Area 3	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	48.42	53.96	57.65	57.65	57.65	57.65	57.65	107.92	115.3	115.3	115.3	115.3	156.34	163.72	163.72	163.72	204.76	212.14	212.14	212.14	253.18	260.56	260.56	260.56	102.38	106.07	106.07	106.07	150.8	154.49	154.49	154.49	199.22	202.91	202.91	202.91	50	See Plan Brochure	50	350	700	350	No Charge	10% Coinsurance after deductible	40% Coinsurance after deductible	Not Covered	No Charge	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02110	Juneau	High	BEST Life and Health Insurance Company	74819	74819AK0010008	BESTDental Standard - H	PPO	Rating Area 3	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	48.42	48.16	51.46	51.46	51.46	51.46	51.46	96.32	102.92	102.92	102.92	102.92	144.74	151.34	151.34	151.34	193.16	199.76	199.76	199.76	241.58	248.18	248.18	248.18	96.58	99.88	99.88	99.88	145	148.3	148.3	148.3	193.42	196.72	196.72	196.72	50	See Plan Brochure	50	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02110	Juneau	High	BEST Life and Health Insurance Company	74819	74819AK0010010	BESTDental Choice - H	PPO	Rating Area 3	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	48.42	45.32	48.41	48.41	48.41	48.41	48.41	90.64	96.82	96.82	96.82	96.82	139.06	145.24	145.24	145.24	187.48	193.66	193.66	193.66	235.9	242.08	242.08	242.08	93.74	96.83	96.83	96.83	142.16	145.25	145.25	145.25	190.58	193.67	193.67	193.67	50	See Plan Brochure	50	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02110	Juneau	High	Oregon Dental Service	21989	21989AK0090001	Delta Dental Premier Practical Plan 1000	Indemnity	Rating Area 3	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf	X	X	X	X	X	X	X	64	58	58	58	58	58	58	116	116	116	116	116	180	180	180	180	244	244	244	244	308	308	308	308	122	122	122	122	186	186	186	186	250	250	250	250	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02110	Juneau	High	Oregon Dental Service	21989	21989AK0090002	Delta Dental Premier Practical Plan 1500	Indemnity	Rating Area 3	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf	X	X	X	X	X	X	X	74	67	67	67	67	67	67	134	134	134	134	134	208	208	208	208	282	282	282	282	356	356	356	356	141	141	141	141	215	215	215	215	289	289	289	289	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02130	Ketchikan Gateway	High	BEST Life and Health Insurance Company	74819	74819AK0010007	BESTDental Premium	PPO	Rating Area 3	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	48.42	53.96	57.65	57.65	57.65	57.65	57.65	107.92	115.3	115.3	115.3	115.3	156.34	163.72	163.72	163.72	204.76	212.14	212.14	212.14	253.18	260.56	260.56	260.56	102.38	106.07	106.07	106.07	150.8	154.49	154.49	154.49	199.22	202.91	202.91	202.91	50	See Plan Brochure	50	350	700	350	No Charge	10% Coinsurance after deductible	40% Coinsurance after deductible	Not Covered	No Charge	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02130	Ketchikan Gateway	High	BEST Life and Health Insurance Company	74819	74819AK0010008	BESTDental Standard - H	PPO	Rating Area 3	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	48.42	48.16	51.46	51.46	51.46	51.46	51.46	96.32	102.92	102.92	102.92	102.92	144.74	151.34	151.34	151.34	193.16	199.76	199.76	199.76	241.58	248.18	248.18	248.18	96.58	99.88	99.88	99.88	145	148.3	148.3	148.3	193.42	196.72	196.72	196.72	50	See Plan Brochure	50	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02130	Ketchikan Gateway	High	BEST Life and Health Insurance Company	74819	74819AK0010010	BESTDental Choice - H	PPO	Rating Area 3	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	48.42	45.32	48.41	48.41	48.41	48.41	48.41	90.64	96.82	96.82	96.82	96.82	139.06	145.24	145.24	145.24	187.48	193.66	193.66	193.66	235.9	242.08	242.08	242.08	93.74	96.83	96.83	96.83	142.16	145.25	145.25	145.25	190.58	193.67	193.67	193.67	50	See Plan Brochure	50	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02164	Lake And Peninsula	High	Oregon Dental Service	21989	21989AK0090001	Delta Dental Premier Practical Plan 1000	Indemnity	Rating Area 2	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf	X	X	X	X	X	X	X	64	58	58	58	58	58	58	116	116	116	116	116	180	180	180	180	244	244	244	244	308	308	308	308	122	122	122	122	186	186	186	186	250	250	250	250	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02164	Lake And Peninsula	High	Oregon Dental Service	21989	21989AK0090002	Delta Dental Premier Practical Plan 1500	Indemnity	Rating Area 2	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf	X	X	X	X	X	X	X	74	67	67	67	67	67	67	134	134	134	134	134	208	208	208	208	282	282	282	282	356	356	356	356	141	141	141	141	215	215	215	215	289	289	289	289	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02180	Nome	Low	BEST Life and Health Insurance Company	74819	74819AK0010009	BESTDental Standard - L	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	49.04	52.39	52.39	52.39	52.39	52.39	98.08	104.78	104.78	104.78	104.78	136.25	142.95	142.95	142.95	174.42	181.12	181.12	181.12	212.59	219.29	219.29	219.29	87.21	90.56	90.56	90.56	125.38	128.73	128.73	128.73	163.55	166.9	166.9	166.9	75	See Plan Brochure	75	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02180	Nome	Low	BEST Life and Health Insurance Company	74819	74819AK0010011	BESTDental Choice - L	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	46.14	49.29	49.29	49.29	49.29	49.29	92.28	98.58	98.58	98.58	98.58	130.45	136.75	136.75	136.75	168.62	174.92	174.92	174.92	206.79	213.09	213.09	213.09	84.31	87.46	87.46	87.46	122.48	125.63	125.63	125.63	160.65	163.8	163.8	163.8	75	See Plan Brochure	75	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02180	Nome	Low	BEST Life and Health Insurance Company	74819	74819AK0010012	BESTDental Value	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	38.17	32.03	34.21	34.21	34.21	34.21	34.21	64.06	68.42	68.42	68.42	68.42	102.23	106.59	106.59	106.59	140.4	144.76	144.76	144.76	178.57	182.93	182.93	182.93	70.2	72.38	72.38	72.38	108.37	110.55	110.55	110.55	146.54	148.72	148.72	148.72	75	See Plan Brochure	75	350	700	350	No Charge	40% Coinsurance after deductible	60% Coinsurance after deductible	Not Covered	No Charge after Deductible	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02188	Northwest Arctic	High	BEST Life and Health Insurance Company	74819	74819AK0010007	BESTDental Premium	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	49.3	54.94	58.7	58.7	58.7	58.7	58.7	109.88	117.4	117.4	117.4	117.4	159.18	166.7	166.7	166.7	208.48	216	216	216	257.78	265.3	265.3	265.3	104.24	108	108	108	153.54	157.3	157.3	157.3	202.84	206.6	206.6	206.6	50	See Plan Brochure	50	350	700	350	No Charge	10% Coinsurance after deductible	40% Coinsurance after deductible	Not Covered	No Charge	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02188	Northwest Arctic	High	BEST Life and Health Insurance Company	74819	74819AK0010008	BESTDental Standard - H	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	49.3	49.04	52.39	52.39	52.39	52.39	52.39	98.08	104.78	104.78	104.78	104.78	147.38	154.08	154.08	154.08	196.68	203.38	203.38	203.38	245.98	252.68	252.68	252.68	98.34	101.69	101.69	101.69	147.64	150.99	150.99	150.99	196.94	200.29	200.29	200.29	50	See Plan Brochure	50	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02188	Northwest Arctic	High	BEST Life and Health Insurance Company	74819	74819AK0010010	BESTDental Choice - H	PPO	Rating Area 2	Allows Adult and Child-Only	HIOS	1-949-253-4080	1-800-433-0088	1-949-222-2134	http://www.bestlife.com/Provider_Search/		X	X	X	X	X	X	X	49.3	46.14	49.29	49.29	49.29	49.29	49.29	92.28	98.58	98.58	98.58	98.58	141.58	147.88	147.88	147.88	190.88	197.18	197.18	197.18	240.18	246.48	246.48	246.48	95.44	98.59	98.59	98.59	144.74	147.89	147.89	147.89	194.04	197.19	197.19	197.19	50	See Plan Brochure	50	350	700	350	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	30% Coinsurance after deductible	50% Coinsurance after deductible	50%
AK	02220	Sitka	High	Oregon Dental Service	21989	21989AK0090001	Delta Dental Premier Practical Plan 1000	Indemnity	Rating Area 3	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf	X	X	X	X	X	X	X	64	58	58	58	58	58	58	116	116	116	116	116	180	180	180	180	244	244	244	244	308	308	308	308	122	122	122	122	186	186	186	186	250	250	250	250	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02220	Sitka	High	Oregon Dental Service	21989	21989AK0090002	Delta Dental Premier Practical Plan 1500	Indemnity	Rating Area 3	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf	X	X	X	X	X	X	X	74	67	67	67	67	67	67	134	134	134	134	134	208	208	208	208	282	282	282	282	356	356	356	356	141	141	141	141	215	215	215	215	289	289	289	289	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible
AK	02240	Southeast Fairbanks	High	Oregon Dental Service	21989	21989AK0090001	Delta Dental Premier Practical Plan 1000	Indemnity	Rating Area 2	Allows Adult and Child-Only	HIOS	1-844-235-8014	1-844-235-8014	1-844-235-8014	https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml	https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf	X	X	X	X	X	X	X	64	58	58	58	58	58	58	116	116	116	116	116	180	180	180	180	244	244	244	244	308	308	308	308	122	122	122	122	186	186	186	186	250	250	250	250	50	$150	50	350	700	350	20%	20% Coinsurance after deductible	50% Coinsurance after deductible	Not Covered	No Charge	20% Coinsurance after deductible	50% Coinsurance after deductible	50% Coinsurance after deductible

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