Covered Dental Services In-Network* 
You Pay Out-Of- 
Network** 
You Pay Benefit Limitations Per 
Calendar Year 
Preventive and Diagnostic Dental Services 
Periodic oral exam 
Emergency diagnostic exam 0% 
0% 50% 
50% Two per year 
Periodontal exam 
Comprehensive oral evaluation 0% 
0% 50% 
50% One procedure every 
three years 
Dental prophylaxis (cleanings) 0% 50% Two per year 
Fluoride treatment 0% 50% Two per year 
Bitewing X-ray 0% 50% One set per year 
Intraoral X-ray 0% 50% One set per year