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 PREVENTATlVE
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 33-34	$500.00
Abut. Placement Substitution End, see limitations page 33-34	$500.00
Surg. Placement Eposteal Implant, see limitations page 33-34	$500.00
Surg. Placement Transosteal Impl, see limitations page 33-34	$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. ORTHODONTICS SERVICES
Removable Appliance Therapy	$270.00
Interceptive Fixer Appliance	$450.00
Interceptive Passive Per 3 Mon	$65.00
Interceptive Active Treatment	$65.00
Retainer For Passive Treatment	$100.00
VIII. 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