Benefit Maximum:
Per Person, Per Plan Year: $2000

Deductible:
Per Person, Per Plan Year: $50 for Type 2 & 3
Type 1 deductible wavied
No family maximum

Insured Percent:

Type 1	100%
Type 2	80%
Type 3	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
• Denture Repair
• Simple extractions

Type 3 Services (No Waiting Periods)

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