| Calendar year maximum, per member | $1,000 | |||||||||
| Calendar year deductible, per member | $50 | |||||||||
| - | Oral Surgery (surgical extractions & certain minor surgical procedures) | |||||||||
| - | Endodontic (pulp therapy & root canal filling) | |||||||||
| - | Periodontics (treatment of tissues supporting the teeth) | |||||||||
| MAJOR (12-month waiting period applies) | 50% | |||||||||
| - | Crowns | |||||||||
| - | Cast Restorations | |||||||||
| - | Denture and Bridge Work (construction or repair of fixed bridges, | |||||||||
| partials, and complete dentures) | ||||||||||
| LIMITATIONS | ||||||||||