The following is a listing of dental procedures covered under Your dental plan. Only procedures listed in the following schedule are eligible for coverage:

PROCEDURE	MAXIMUM PLAN ALLOWANCES
I. DIAGNOSTIC AND PREVENTATIVE
Comprehensive Oral Examination (once every six (6) months)	$25.00
X-Rays Complete Series	$50.00
X-Ray Periapical 1st Film	$4.00
X-Ray Periapical Each Addl.	$4.00
X-Ray Occlusal Film	$16.00
X-Ray Extraoral Film	$25.00
X-Ray Bitewing	$4.00
X-Rays 2 Bitewings	$8.00
X-Rays 4 Bitewings	$16.00
X-Ray Sialography	$40.00
X-Ray Temporomandibular Joint	$25.00
X-Ray Panoramic Film	$45.00
X-Ray Cephalometric Film	$35.00
Dental Prophylaxis Adult (once every six (6) months)	$45.00
Dental Prophylaxis Child to 16 (once every six (6) months)	$40.00
Fluoride Treatment to Age 19 (once per year)	$16.00
Sealant Per Tooth to Age 19	$20.00
Space Maintainer Fixed Unilate	$150.00
Space Maintainer Fixer Bilater	$150.00
Space Maintainer Remove Unilate	$150.00
Space Maintainer Remove Bilater	$150.00
Recement Space Maintainer	$30.00
II. RESTORATIVE
Amalgam Fillings
Amalgam 1 Surface, Amalgam 2 Surfaces, Prim., Perm	$60.00
Amalgam 3 Surfaces, Prim., Perm	$65.00
Amalgam, Prim., Perm	$50.00
4+ Surfaces, Prim., Perm	$75.00
Resin Fillings
Composite 1 Surface Anterior	$60.00
Composite 2 Surfaces Anterior	$65.00
Composite 3 Surfaces Anterior	$70.00
Composite 4+ Surfaces/Incisal Anterior	$75.00
Composite 1 Surface Posterior	$70.00
Composite 2 Surfaces Posterior	$85.00
Composite 3 Surfaces Posterior	$95.00
Composite 4+ Surfaces Posterior	$95.00
Inays/Onlays
Inlay Metallic 1 Surface	$150.00
Inlay Metallic 2 Surfaces	$180.00
Inlay Metallic 3 or more Surfaces	$210.00
Onlay Metallic 2 Surfaces	$180.00
Onlay Metallic 3 Surfaces	$210.00
Onlay Metallic 4+ Surfaces	$210.00
Inlay Porce/Ceramic 1 Surface	$150.00
Inlay Porce/Ceramic 2 Surfaces	$180.00
Inlay Porce/Ceramic 3+ Surfaces	$210.00
Onlay Porce/Ceramic 2 Surfaces	$180.00
Onlay Porce/Ceramic 3 Surfaces	$210.00
Onlay Porce/Ceramic 4+ Surfaces	$210.00
Crowns
Crown Resin (Indirect)	$175.00
Crown Resin High Noble Metal	$300.00
Crown Porcelain High Noble Metal	$400.00
Crown Porcelain Noble Metal	$400.00
Crown 3/4 Cast Noble Metal	$300.00
Crown Full Cast High Noble Metal	$300.00
Recement Inlay	$40.00
Recement Crown	$40.00
Stainless Steel Crown-Primary	$100.00
Stainless Steel Crown Primary	$100.00
Pin Retention Per Tooth	$25.00
Cast Post and Core	$125.00
Prefabricated Post and Core	$95.00
Labial Veneer-Laboratory	$200.00
III. ENDODONTICS
Pulp Cap Direct	$20.00
Pulp Cap Indirect	$20.00
Therapeutic Pulpotomy	$60.00
Root Canal Anterior	$350.00
Root Canal Bicuspid	$400.00
Root Canal Molar	$450.00
Apicoectomy Anterior	$200.00
Apicoectomy Bicuspid 1st Root	$200.00
Apicoectomy Molar 1st Root	$200.00
Apicoectomy Each addl. Root	$100.00
Retrograde Filling Per Root	$85.00
Root Amputation Peer Root	$150.00
Hemisection	$150.00
IV. PERIODONTICS
Gingivectomy/Plasty-Per Quad	$150.00
Osseous Surgery Per Quad	$400.00
Bone Replacement Grft- 1st Site	$150.00
Bone Replacement Grft Each Addl	$250.00
Pedicle Soft Tissue Graft	$200.00
Free Soft Tissue Graft	$200.00
Perio Scaling Rt. Planning Quad	$50.00
Periodontal Maintenance	$60.00
V. PROSTHODONTICS
Complete Denture Maxillary	$600.00
Complete Denture Mandibular	$600.00
Immediate Denture Maxillary	$600.00
Immediate Denture Mandibular	$600.00
Prtl. Dent. Max w/Clasps Resin	$375.00
Prtl. Dent Mand w/Clasps Resin	$375.00
Prtl. Dent Max w/Clasps Cast	$600.00
Prtl. Dent Mand w/Clasps Cast	$600.00
Removable Unilateral Prtl. 1 Tooth	$175.00
Adjust Complete Denture Max	$35.00
Adjust Complete Denture Mand	$35.00
Adjust Partial Denture Max	$35.00
Adjust Partial Denture Mand	$35.00
Repair Brkn Complete Dent Base	$90.00
Replace Miss/Broken Tth Comp. Dnt	$85.00
Repair Prtl. Resin Denture Base	$90.00
Repair Prtl. Cast Framework	$100.00
Repair or Replace Broken Clasp	$85.00
Replace Broken Tth. Per Tooth	$85.00
Add Tooth To Partial Denture	$85.00
Add Clasp to Partial Denture	$85.00
Reline Complete Dent Max Chair	$75.00
Reline Complete Dnt Mand. Chair	$75.00
Reline Partial Dent Max Chair	$70.00
Reline Partial Dent Mand Chair	$70.00
Reline Complete Dent Max Lab	$125.00
Reline Complete Dent Mand Lab	$125.00
Reline Dent Max Lab	$100.00
Reline Partial Dent Mann Lab	$100.00
Tissue Conditioning Maxillary	$40.00
Tissue Conditioning Mandibular	$40.00
Precision Attachment	$100.00
Surg. Placement Implant Endosteal, see limitations page 30	$500.00
Abut. Placement Substitution End, see limitations page 30	$500.00
Surg. Placement Eposteal Implant, see limitations page 30	$500.00
Surg. Placement Transosteal Impl, see limitations page 30	$500.00
Pontic Cast High Noble Metal	$350.00
Pontic Porcelain High Noble	$400.00
Pontic Porcelain Prenom, Base Metal	$400.00
Pontic Porcelain Noble Metal	$400.00
Pontic Resin High Noble Metal	$350.00
Retainer Cast Metal For Resin	$200.00
Abutment Resin High Noble Metal	$350.00
Abutment Porcelain High Noble	$400.00
Abutment Porce. Predom. Base Metal	$400.00
Abutment Porcelain High Noble	$400.00
Abutment Full Cast High Noble	$350.00
Recement Fixed Partial Denture	$60.00
VI. ORAL SURGERY
Extraction Erupted Tth Exposed	$90.00
Surgical Removal Erupted Tooth	$90.00
Removal Impacted Tth Soft Tissue	$150.00
Removal Impacted Tth Prtl. Bony	$235.00
Removal Impacted Tth Full Bony	$300.00
Surgical Removal Residual Root	$90.00
Surgical Access Unerupted Tth	$160.00
Surg. Exposure Impacted Tth Aid.	$80.00
Biopsy Of Oral Tissue Hard	$75.00
Biopsy Of Oral Tissue Soft	$75.00
Alveoloplasty w/Ext Per Quad	$125.00
Alveoloplasty w/out Ext Quad	$125.00
Removal Benign Odonto. Cyst < 1.25 CM	$75.00
Removal Benign Odonto Cyst >1.25 CM	$125.00
Incision & Drainage Intraoral	$50.00
incision & Drainage Extraoral	$50.00
Frenectomy	$95.00
VII. ADJUNCTIVE SERVICES
Palliative Treatment	$30.00
Deep Sed. Gen. Anesthesia 1st 30 Mm	$100.00
Deep Sed. Gen Anesthesia Each Addl. 15	$50.00
Consultation by Specialist	$50.00