In-Network
Out-of-Network
Preventive Services
Routine oral exams Bitewing X-rays Full-mouth or panoramic X-rays Other dental X-rays (including periapical films) Routine cleanings Fluoride treatments Space maintainers for children Sealants
100% No Deductible
80% No Deductible
In-Network
Out-of-Network
Basic Services
Problem-focused exams Consultations
Palliative treatment (including emergency relief of dental pain) Injections of antibiotics and other therapeutic medications Fillings Simple extractions Periodontal maintenance procedures Labs & other tests
80% After Deductible
60% After Deductible
In-Network
Out-of-Network
Major Services
Prefabricated stainless steel and resin crowns Surgical extractions Oral surgery Biopsy and examination of oral tissue (including brush biopsy) General anesthesia and I.V. sedation
Prosthetic repair and recementation services Endodontics (including root canal treatment) Non-surgical periodontal therapy Periodontal surgery Bridges Full and partial dentures Denture reline and rebase services Crowns, inlays, onlays and related services
50% After Deductible
50% After Deductible
In-Network
Out-of-Network
Orthodontics
Orthodontic exams X-rays Extractions Study models Appliances
50%
50%
Dental Coverage Benefits At-A-Glance
GP-DENT-FLI001
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