Emergency treatment for pain 50% 55% Two per year 
Anesthesia 0% 50% Unlimited procedures per year 
Major Dental Services (Endodontics, Periodontics, and Oral Surgery) 
Crowns 70% 75% Two per year 
Periodontal scaling and root 
planing (deep cleaning) 70% 75% One procedure for each quadrant 
every three years 
Scaling –generalized 
inflammation  70% 75% One procedure every three years 
Covered dental services are subject to conditions, limitations, exclusions, and maximums. Please see your