Covered Dental Services In-Network* 
You Pay Out-Of- 
Network** 
You Pay Benefit Limitations Per 
Calendar Year 
Basic Dental Services (Minor Restorative) 
Extractions (pulling teeth), simple 
or surgical 50% 55% Two per year 
Recementation –Crown 50% 55% One procedure every five years 
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