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Annual Maximum
Diagnostic –
Preventive
Oral Exam
Cleanings (every six months)
Fluoride to age 14
X-rays
Restorative
Silver Amalgams
Composite Fillings (front teeth)
Endodontics
Single Root Canal
Double Root Canal
Triple or more Root Canal Filling
Apicoectomy
Periodontics
Root Scaling and Planing
Gingivectomy, Gingivoplasty (per quadrant)
Osseous Surgery (per quadrant)
Oral Surgery Extractions
Extraction of Erupted Tooth
Extraction of Soft Bony Impaction
Extraction of Partial Bony Impaction
Extraction of Complete Bony Impaction
Prosthetics
Crowns
Dentures
Bridgework (Exclusions Apply)
Orthodontics -
Comprehensive
To age 19 (Maximum, Twenty-four months)
Over Age 19
This is a brief benefit summary. For a
complete explanation of
benefits as well as exclusions and Limitations call toll free
1-800-544-6374 or 313-581-6824.
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None
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
$1,250.00 Copay
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