Basic Option offers coverage for a number of routine dental care procedures. For each evaluation you pay a $20 copayment and Blue Cross Blue Shield takes care of the rest. In order to receive benefits, you must use a Preferred dentist, except if dental care is required due to an accidental injury.

Below is a complete list of the covered procedures and fee schedule amounts. Any service not listed is not covered.

Clinical Oral Evaluations

Services	We Pay	You Pay
Periodic oral evaluation* Limited oral evaluation Comprehensive oral evaluation*	All charges in excess of your $20 copayment	$20 copayment per evaluation

Radiographs

Services	We Pay	You Pay
Intraoral complete series, including bitewings (limited to 1 complete series every 3 years) Bitewing — single film** Bitewings — two films** Bitewings — four films**	All charges in excess of your $20 copayment	$20 copayment per evaluation

Preventive

Services	We Pay	You Pay
Prophylaxis — adult*** Prophylaxis — child*** Topical application of fluoride (including prophylaxis) — child*** Topical application of fluoride (prophylaxis not included) — child*** Sealant — per tooth, first and second molars only (once per tooth for children up to age 16 only)	All charges in excess of your $20 copayment	$20 copayment per evaluation

* Benefits are limited to a combined total of two evaluations and two prophylaxis per person per calendar year.

** Benefits are limited to a combined total of four films per person per calendar year.

*** Benefits are limited to a combined total of two visits per person per calendar year.