surgery, periodic oral exam, prophylaxis (cleaning) up to 2per year. 
•$0 copay for periodontal maintenance up to 4per year. 
•$0 copay for amalgam and/or composite filling, necessary  
anesthesia with covered service, simple or surgical extraction up to  
unlimited per year. 
•$5000 maximum benefit coverage amount per year for preventive  
and comprehensive benefits. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs