Benefit Maximum:
Per Person, Per Plan Year: $1500

Deductible:
(applies to Type 2 and 3 services only)

Per Person, Per Plan Year: $50
Type 1 deductible wavied
No family maximum

Insured Percent:

	Type 1	Type 2	Type 3
	100%	80%	50%

Type 1 Services (No Waiting Periods)

• Routine Oral Exams (Once every 6 Months)
• Routine Dental Cleaning (Once every 6 Months) (Frequencies combined with periodontal maintenance)
• Bitewing x-rays (once every 12 months)
• Flouride treatments* (once every 12 months) For children 13 and under one per benefit period.
• Sealants* - Age 13 and under.
• Space maintainers
• X-Rays: - Complete mouth or panoramic - (once every 60 months), -Other x-rays.
• Periapical X-Rays
• Full Mouth Panoramic X-Rays (Once every 5 years)
  

Type 2 Services (No Waiting Periods)

• Restorative Amalgams
• Restorative Composites
• Endodontics (nonsurgical)
• Endodontics (surgical)
• Periodontics (nonsurgical)
• Periodontics (surgical)
• Denture Repair
• Simple extractions

Type 3 Services (No Waiting Periods)

• Onlays
• Crowns
  (1 in 10 years per tooth)
• Crown Repair
• Implants
• Prosthodontics (fixed bridge; removable complete/partial dentures)
  (1 in 10 years)
• Complex Extractions
• Anesthesia