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City of Santa kna <br />*a Exhibit A - <br />Safeauard Prepaid Dental Plan <br />..... ... <br />100 S-Z <br />Sxfeguar -Year Plaz (Current PIRu" x <br />1 C*% <br />F uar <br />100 <br />00 7?- <br />1 <br />Extractionr: Kingtr,- <br />100% <br />100% <br />100% <br />mlivn <br />P <br />'et • <br />Y <br />YcAr <br />Yca r <br />Year 4 <br />-Y <br />100% <br />T <br />u r <br />P V <br />vJ e . <br />-Y <br />1 130 X& M <br />300% <br />100%. <br />100 6C <br />100 5� <br />10 0 5r.- <br />PIZ PaTirl'o <br />10 IV, <br />100% <br />100%. <br />100 FC' <br />100 <br />0 <br />100 5rr <br />100 <br />100 5� <br />100% 100%. <br />1009, <br />Rd tit iia'6'* + + <br />1005ro <br />w: <br />single, imalgam <br />100 S-Z <br />100% <br />1 C*% <br />100 <br />00 7?- <br />1 <br />Extractionr: Kingtr,- <br />100% <br />100% <br />100% <br />100% <br />100% <br />j 009; <br />1MP'1W*0n: soft lisgut <br />10-0 5; <br />100% <br />100% <br />100% <br />100% <br />u r <br />i <br />Acrylic C-Town <br />4T <br />-Y <br />100% <br />rr ID rpm <br />ILPPLW4 th PNU. <br />PIZ PaTirl'o <br />a PPLI* <br />it <br />S75 <br />$75 <br />PorceWn Crown <br />1005ro <br />w: <br />C—V <br />Gingiveetomy per quadrant 100% 100% 1 W 100% 100% <br />WU <br />Molar l00%-, icy t00% IGO% % 100 nr <br />I 100 <br />plop' -1. — <br />+ + <br />_kt, <br />�Iv'! 4%> <br />. ......... <br />Full banded: oUd 5500* MOW S500* 5500* SLOW <br />miult r 18MO) (same) 4 it rn it,) SLOW <br />Start-up Foo.c none none none none 5200 <br />V� V <br />OuL of ATcz Up to S50 - no charge Up to $50 <br />no charge <br />Emplovep, S12.84 512.84 <br />F a MAY 522-00 524-64 <br />4i- '�A ..... <br />P <br />of year& Rate cxpirr, October 092 YC,'3 n <br />W- I <br />FuU orlho6ontk. treatment is limited to -3 v1siti during tbc, fint 12 months of orthodonfi r- Lreatmcnt at no char gc. , and 421 offjccl <br />Yisitz c h 12 month period thcreaftr-r A, no chargr,- off= visits ifl ex of thosc, limits arc charged at the t e- of S20-00 <br />4 <br />por offlor, visit. The maximum number of visiu per oacb 12 month peFnod of adhodantk, treatment is It. <br />Not.-.: Currently, there is a one-y"r mrahing period for orthodontic treamcnt- Therc. will nt--it be. R waiting pmiod cinder the nc-%v <br />plan, cffc-ct-ivc October 1, 1992 <br />095 12F <br />