Page 9 Preventive Services Benefit Evaluations • Periodic Oral Evaluation 100% • Limited Oral Evaluation – problem focused 100% • Comprehensive Oral Evaluation 100% Treatments • Routine Dental Prophylaxis 100% • Fluoride Treatment 100% • Sealants – child 100% X-Rays • Periapical X-Rays 100% • Bitewing X-Rays 100% Periodontal Maintenance 100% Basic Services Benefit X-Rays • Complete Series/ Panoramic X-Rays 80% Emergency Palliative Treatment 80% Surgical Extractions and Removal of Impacted Teeth 80% Basic Restorative Services (amalgam, composite resin, acrylic, synthetic or plastic fillings) 80% Simple Extractions 80% Surgical Endodontics 80% Non-Surgical Endodontics 80% Non-Surgical Periodontal 80% Oral Surgery 80% Periodontal Surgery 80% Major Services Benefit Inlays/Onlays/Crowns 50% Dentures – complete, partial, overdenture (upper and lower) 50% Implants 50% Bridges 50% Orthodontic Services Benefit Child Orthodontic Services 50%