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 per year 
Panoramic or diagnostic X-ray 0% 50% One every three years 
Periodontal maintenance 0% 50% Four per year 
Basic Dental Services (Minor Restorative) 
Amalgam restorations (silver 
fillings) 
Composite resin restorations 
(white fillings) 50% 
50% 55%