Dental Care Maximums	$1500 annual maximum
	$500 periodontics maximum
	$750 orthodontics maximum

Dental Benefits: Scheduled amounts are payable up to $1,500 per covered person per calendar year for preventative and diagnostic care, restorative treatment, root canals, periodontics ($500 lifetime maximum), oral surgery and orthodontia ($750 maximum per course of treatment). Some benefits require a 12 month waiting period before benefits are available. (See Schedule of Benefits on page 6.)

Survivor Benefit: Dependent coverage will continue—premium free—for up to 18 months after the end of the month in which the insured employee's death occurs.

Schedule of Benefits

Category	Benefit Amount
Type 1:   Preventive & Diagnostic
a)       Oral exams, including prophylaxis	$48.00
b)       Bitewings, per film	$6.40
c)       X-ray, panoramic or cephalometric	$48.00
d)       Sealants / topical fluoride	$13.60
e)       Space maintainers	$144.00
Type 2:   Major Restorative
a)       Crowns, bridges & dentures	$240.00
b)       Pre-fabricated crowns	$80.00
c)       Crown build-up procedures	$6400
Type 3:   Minor Restorative
a)       Fillings	$56.00
b)       Crown, bridge and denture repairs	$32.00
c)       Relining or rebasing dentures	$80.00
Type 4:   Endodontics
a)       Root canals, apicoectomies	$256.00
b)       Root amputation	$128.00
c)       Therapeutic pulpotomy, retrograde fillings, apexification, hemisection	$64.00
Type 5:   Periodontics ($500 Lifetime Maximum)
a)       Tissue grafts or bone surgery	$128.00
b)       Gingivectomy (per quadrant), periodontal scaling, periodontal periodontal scaling, periodontal splinting, root planing	$80.00
c)       Gingival curettage (per quadrant)	$48.00
d)       Gingivectomy (per tooth)	$32.00
Type 6:   Oral Surgery
a)       Surgeries Level 1 (ex. Removal of exostosis)	$160.00
b)       Surgeries Level 2 (ex. Removal of impacted tooth)	$88.00
c)       Surgeries Level 3 (ex. Simple extraction)	$48.00
Type 7:   General Anesthesia and IV
a)       IV, first half hour general, each additional 1/4 hour general	$96.00
Type 8:   Orthodontia (Per Course of Treatment)	$750.00
Types 1 through 7 subject to annual maximum of:	$1500.00
Types 2, 5, 6a, 7 and 8 are subject to 12 month waiting period

RATES