Summary of Benefits for Plan 1

Diagnostic & Preventative Care

 DIAGNOSTIC - 100%

• Oral Examinations
• Office Visits
• Diagnostic Casts
• Dental X-Rays
• Professional Consultation

 PREVENTIVE - 100%

• Plaque Control, Oral Hygiene Instructions
• Prophylaxis (Cleaning; Once in a Six-Month Period)
• Preventive Dental Hygiene
• Topical Applications of Fluoride (Up to Age 14)
• Sealants (Up to Age 14 on Permanent Molars Only)

 ANNUAL NON-ORTHODONTIC MAXIMUM - $1200