| Coverage Details |  | |
| Type 1 Preventive & Diagnostic | |
| a. Oral exams, including prophylaxis | $36.00 |
| b. Bitewings, per film | $4.80 |
| c. X-ray, panoramic or cephalometric | $36.00 |
| d. Sealants/topical fluoride | $10.20 |
| e. Space maintainers | $108.00 |
|
| Type 2 Major Restorative | | |
| a. Crowns, bridges and dentures | $180.00 |
| b. Pre-fabricated crowns | $60.00 |
| c. Crown build-up procedures | $48.00 |
|
| Type 3 Minor Restorative | | |
| a. Fillings | $42.00 |
| b. Crown, bridge and denture repairs | $24.00 |
| c. Relining or rebasing dentures | $60.00 |
|
| Type 4 Endodontics | | |
| a. Root canals, apicoectomies | $192.00 |
| b. Root amputation | $96.00 |
| c. Therapeutic pulpotomy, retrograde fillings, apexification, and hemisection | $48.00 |
|
| Type 5 Periodontics ($500 Lifetime Maximum) | | |
| a. Tissue grafts or bone surgery | $96.00 |
| b. Gingival curettage (per quadrant) | $36.00 |
| c. Gingivectomy (per tooth) | $24.00 |
| d. Gingivectomy (per quadrant), periodontal scaling, periodontal splinting, and root planing | $60.00 |
|
| Type 6 Oral Surgery | | |
| a. Surgeries Level 1 (removal of exostosis) | $120.00 |
| b. Surgeries Level 2 (removal of impacted tooth) | $66.00 |
| c. Surgeries Level 3 (simple extraction) | $36.00 |
|
| Type 7 General Anesthesia and IV | | |
| a. IV, first half hour general, each additional 1/4 hour general | $72.00 |
|
| Type 8 Orthodontia (Adult or Child - Per Course of Treatment) | | $750.00 |
|
| Annual Maximum | | |
| Types 1 through 7 | $1,500.00 |
|
| | Waiting Period | | | 12-month waiting period applicable to Types 2, 5, 6a, 7 and 8 |
|
