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. 
•50% of the cost for oral surgery  
up to 2per year. 
•$2000 combined maximum  
benefit coverage amount per  
year for preventive and  
comprehensive benefits. 
•Benefits received  
out-of-network are subject to  
any in-network benefit  
maximums, limitations, and/or