reline, denture repair, emergency diagnostic exam, tissue  
conditioning up to 1per year. 
•$0 copay for emergency treatment for pain, fluoride treatment, oral  
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. 
•$3000 maximum benefit coverage amount per year for preventive