| Diagnostic and Preventive Benefits |
Oral exams and cleanings, fluoride applications, sealants, bitewing x-rays, full-mouth x-rays, space maintainers |
100% |
| Basic Benefits |
Root canals (anterior or bicuspid), amalgam (silver) fillings, composite fillings (anterior only), stainless steel crowns, scaling and root planing, gingivectomy, abscess incision and drainage, uncomplicated extractions, surgical removal of erupted or impacted tooth (soft) |
80% |
| Major Benefits |
Root canals (molars), Osseous surgery, surgical removal of impacted tooth (full or partial bony), general anesthesia/intravenous sedation, inlays/onlays, crowns, bridges, full and partial dentures, denture repairs, pontics |
50% |
| Orthodontics |
Dependents under age 20; $1,000 lifetime maximum; $0 deductible |
50% |
