• Complete oral examination, once every 36 months
• Recall oral examination, once every 12 months
• Specific oral examination, once every 6 months
• Emergency oral examination

• Complete series of periapical films or panoramic radiographs, limited to one series in any 24 months
• Intra oral films and radiographs to diagnose a symptom or examine progress of a particular course of treatment
• Bitewing films, limited to a maximum of 4 films every 12 months
• Interpretation of radiographs from another source
• Photography
• Radiograph of the hand and wrist as a diagnostic aid for dental treatment

• Bacteriologic cultures/smears to determine pathological agents
• Biopsies
• Pulp vitality test
• Unmounted diagnostic casts

• Consultation with an insured person (a day other than the examination date)

• Oral hygiene instruction, once every 12 months
• Polishing, once every 12 months
• Light scaling for preventive purposes and scaling for therapeutic purposes, limited to a maximum of 2 units per coverage period
• Topical application of fluoride, once every 12 months
• Finishing restorations
• Pit and fissure sealants, for children under age 16
• Interproximal discing
• Space maintainers for missing primary teeth, for children under age 16
• Prophylactic odontotomy/enameloplasty

• Amalgam (silver)
• Composite restorations performed on posterior teeth are limited to the fees for amalgam restorations
• Retentive pins for amalgam and composite restorations
• Preformed stainless steel and polycarbonate crowns, for children under age 16
• Caries/trauma/pain control, separate procedure from restoration

• Treatment of disease of the pulp chamber and pulp canals (root canal therapy)

Treatment of the gums (soft tissue) and bone supporting the teeth. However, the following expenses are limited:

1. post-operative visits, 4 visits per coverage period
2. curettage performed by a dentist, once per period of 60 months
3. adjustments to periodontal appliance to control bruxism only, limited to one adjustment per coverage period
4. occlusal equilibration, limited to a maximum of 8 units per period of 12 months or one major and 3 minors per period of 12 months

• Repair
• Structure addition (to an existing removable denture)
• Relining
• Rebasing
• Adjustments to dentures, 3 months after insertion
• Denture adjustments including minor adjustments, once every 6 months

• Extractions - uncomplicated and complex. Wisdom teeth extractions are limited to 2 per coverage period.
• Removal of residual roots
• Surgical exposure of teeth
• Alveoplasty, gingivoplasty, stomatoplasty, and osteoplasty
• Alveolar ridge reconstruction
• Extension of mucous folds
• Excisions
• Incisions
• Frenectomy
• Miscellaneous surgical procedures