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 emergency  
diagnostic exam up to 1per  
year. 
•0% of the cost for fluoride  
treatment, periodic oral exam,  
prophylaxis (cleaning) up to 2  
per year. 
•0% of the cost for periodontal  
maintenance up to 4per year. DEN373 
•0% of the cost for