| DEDUCTIBLE | |
|---|---|
| Calendar Year Deductible (Three per Family) | None |
| PREVENTIVE SERVICES | |
| X-rays (Complete mouth 1 x 36 months) | 90% UCR |
| Cleanings (twice in any period of 12 consecutive months) | |
| Exams (twice in any period of 12 consecutive months) | |
| BASIC SERVICES | |
| Restorations | 90% UCR |
| Extractions | |
| Periodontics | |
| Endodontics | |
| MAJOR SERVICES | |
| Crowns | 90% UCR |
| Inlays | |
| Onlays | |
| Bridgework and Dentures | |
| ORTHODONTICS | |
| Covered for | Adults & Children |
| Covered Percentage | 50% |
| Lifetime maximum benefit | $1,000.00 |
| MAXIMUM | |
| $2,000 per year per person | |
| This chart is only a summary. Please see the evidence of coverage or disclosure form for the selected plan for a thorough description of its benefits, limitations, exclusions and conditions of coverage. | |
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