|Diagnostic and Preventive (includes x-rays, exams, cleaning and sealants)||Free|
|Amalgam Filling: One Surface||Pay 20% of bill|
|Root Canal: Molar||Pay 50% of bill|
|Gingivectomy, Per Tooth||Pay 50% of bill|
|Extraction: Single Tooth, Exposed Root or Erupted||Pay 50% of bill|
|Extraction: Complete Bony||Pay 50% of bill|
|Crown: Porcelain With Metal||Pay 50% of bill|
|Medically Necessary Orthodontia||Children – pay 50% of bill
Not Covered for Adults
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