•$25 copay for crown  
recementation, denture  
recementation up to 1every 5  
years. 
•$25 copay for emergency  
treatment for pain up to 2per  
year. 
•$25 copay per tooth for  
amalgam and/or composite  
filling, simple or surgical  
extraction up to unlimited per  
year. 
•50% of the cost for occlusal  
adjustment up to 1every 3  
years. 
•50% of the cost for bridges up  
to 1every 5years. 
•50% of the cost for crown, root  
canal, root canal retreatment  
up to 1per tooth per lifetime.