•0% of the cost for  
comprehensive oral evaluation  
or periodontal exam up to 1  
every 3years. 
•0% of the cost for panoramic  
film or diagnostic x-rays up to 1  
every 5years. 
•0% of the cost for bitewing  
x-rays, intraoral x-rays up to 1  
set(s) per year. 
•0% of the cost for periodic oral  
exam, prophylaxis (cleaning) up  
to 2per year. 
•0% of the cost for necessary  
anesthesia with covered service  
up to unlimited per year. DEN976 
•50% of the cost for  
comprehensive oral evaluation