Page 2 Orthodontia* is eligible if the initial banding or appliance is inserted while you are covered for Orthodontia under Equitable’s policy, or while you were covered for Orthodontia under your immediate prior carrier. Preventive Services In-Network Benefit Out-of-Network Benefit Evaluations • Periodic Oral Evaluation 100% 100% • Limited Oral Evaluation – problem focused 100% 100% • Comprehensive Oral Evaluation 100% 100% Treatments • Routine Dental Prophylaxis 100% 100% • Fluoride Treatment 100% 100% • Sealants – child 100% 100% X-Rays • Complete Series/ Panoramic X-Rays 100% 100% • Periapical X-Rays 100% 100% • Bitewing X-Rays 100% 100% Basic Services In-Network Benefit Out-of-Network Benefit Emergency Palliative Treatment 100% 100% Surgical Extractions and Removal of Impacted Teeth 100% 100% Basic Restorative Services (amalgam, composite resin, acrylic, synthetic or plastic fillings) 100% 100% Simple Extractions 100% 100% Surgical Endodontics 100% 100% Non-Surgical Endodontics 100% 100% Non-Surgical Periodontal 100% 100% Oral Surgery 100% 100% Periodontal Maintenance 100% 100% Periodontal Surgery 100% 100% Major Services In-Network Benefit Out-of-Network Benefit Inlays/Onlays/Crowns 60% 60% Dentures – complete, partial, overdenture (upper and lower) 60% 60% Implants 60% 60% Bridges 60% 60% Orthodontic Services In-Network Benefit Out-of-Network Benefit Child Orthodontic Services 50% 50%