• Periodic oral evaluation*

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

• Limited oral evaluation

• Comprehensive oral evaluation

• Detailed and extensive oral evaluation

• Intraoral complete series

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

• Intraoral periapical first film

• Intraoral periapical each additional film

• Intraoral occlusal film

• Extraoral first film

• Extraoral each additional film

• Bitewing — single film

• Bitewings — two films

• Bitewings — four films

• Bitewings — vertical

• Posterior — anterior or lateral skull and facial bone survey film

• Panoramic film

• Pulp vitality tests

Preferred: Up to the MAC

Non-preferred: Up to the provider's charge

• Palliative (emergency) treatment of dental pain — minor procedure

• Sedative filling

• Prophylaxis —
  adult*

• Prophylaxis —
  child*

• Topical Application of fluoride, prophylaxis not included — child

• Topical Application of fluoride, prophylaxis not included — adult

• Space maintainer
  — fixed
  — unilateral

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

• Space maintainer
  — fixed
  — bilateral

• Space maintainer
  — removable
  — unilateral

• Space maintainer
  — removable
  — bilateral

• Recementation of space maintainer

• Amalgam —
  one surface, primary or permanent

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

• Amalgam —
  two surfaces, primary or permanent

• Amalgam —
  three surfaces, primary or permanent

• Amalgam —
  four or more surfaces, primary or permanent

• Resin —
  one surface, anterior

• Resin —
  two surfaces, anterior

• Resin —
  three surfaces, anterior

• Resin —
  four or more surfaces or involving incisal angle (anterior)

• Resin-based composite —
  one surface, posterior

• Resin-based composite —
  two surfaces, posterior

• Resin-based composite —
  three surfaces, posterior

• Resin-based composite —
  four or more surfaces, posterior

• Inlay — metallic — one surface

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

• Inlay —
  metallic — two surfaces

• Inlay —
  metallic — three or more surfaces

• Inlay —
  porcelain/ceramic — one surface

• Inlay —
  porcelain/ceramic — two surfaces

• Inlay —
  porcelain/ceramic — three or more surfaces

• Inlay —
  composite/resin — one surface

• Inlay —
  composite/resin — two surfaces

• Inlay —
  composite/resin — three or more surfaces

• Pin retention — per tooth, in addition to restoration

• Extraction, erupted tooth or exposed root

• Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth

• Surgical removal of residual tooth roots (cutting procedure)

• General anesthesia in connection with covered extractions

• Hospital Care

  For severe dental caries in children up to age 22 and for other types of dental procedures when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient.

  Precertification required for inpatient care.

Inpatient: In full after $250 per admission copayment

Unlimited days

Outpatient: Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance (PPA)

Inpatient: $350 per admission copayment

35% of the Plan Allowance (PA)

You may also pay the difference between the provider's charge and our payment

Unlimited days

Outpatient: Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance

You also pay the difference between the provider's charge and the Plan Allowance when you use Non-participating physicians.

• Oral and Maxillofacial Surgery

Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance (PPA)

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance

You also pay the difference between the provider's charge and the Plan Allowance when you use Non-participating physicians.

• Accidental Dental Injury

Subject to the calendar year deductible (Individual or Family)

15% PPA
(physician care)

15% PPA
(facility care)

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance
(physician care)

35% of the Plan Allowance
(facility care)

You also pay the difference between the provider's charge and the Plan Allowance when you use Non-participating physicians or Non-member hospitals.