Routine dental:  
The cost-share indicated below is what you pay for the covered service. 
In-Network: 
DEN046 
•$0 copay for scaling and root planing (deep cleaning) up to 1per  
quadrant every 3years. 
•$0 copay for comprehensive oral evaluation or periodontal exam,  
occlusal adjustment, scaling for moderate inflammation up to 1  
every 3years. 
•$0 copay for bridges, complete dentures, crown recementation,  
denture recementation, panoramic film or diagnostic x-rays, partial