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BENEFITS <br />RATES <br />COVERAGE A — REGULAR SERVICES <br />• Routine periodic examinations at six -month inter- <br />vals, including bitewing x -rays at 12-month intervals. <br />• Full mouth x -rays once in any three -year interval, <br />unless special need is shown. <br />• Dental prophylaxis as prescribed x by the dentist, but <br />not more than once every <br />• Topical fluoride applications as prescribed byo the <br />e <br />dentist, but not more than once in any 2 <br />interval. <br />COVERAGE B — RESTORATIVE SERVICES <br />• Emergency treatment for relief of pain. <br />• Regular restorative services: amalgam, staiss <br />steel crowns, synthetic porcelain and p nle <br />restorations. <br />• Oral surgery: provides for extractions and other oral <br />surgery, including pre- and post- operative care. <br />• Gold restorations when the teeth cannot be restored <br />with another ottbearestored s a <br />with afiling <br />material. <br />• No-surgical c athestr treatment of periodontics: <br />diseasesprocedures <br />the <br />necessary <br />gingiva(gums) and bone supporting the teeth. <br />• Endodontics: includes pulpal therapy and root canal <br />filling. <br />COVERAGE C — PROSTHETICS (REMOVABLE AND <br />FIXED) <br />• Prosthetics — bridges, partial dentures and com- <br />plete dentures. EXCLUSION: Coverage is NOT pro- <br />vided for replacement of misplaced, lost or stolen <br />dental prosthetic appliances. <br />Maximum Benefits: $500.00 per person per coverage year. <br />The Group has the choice of either Plan I or Plan II. <br />PLAN <br />PAYS: <br />80% <br />80% <br />50% <br />PLAN I <br />DEDUCTIBLE: $25. person per <br />year <br />a maximum of three <br />deductibles ($75) for <br />any family unit. <br />Deductible does NOT <br />apply to Coverage A. <br />RATES: FAMILY: $17.90 per month <br />mom- ;Af Rp.scrir)tion is subject to the terms <br />PLAN II <br />1 <br />DEDUCTIBLE: cove agee year rwith par <br />maximum of three <br />deductibles ($150) for <br />any family unit. <br />Deductible does NOT <br />apply to Coverage A. <br />SINGLE: $ 5.95 per mon <br />FAMILY: $14.90 per mon <br />rl RATES: <br />of the Delta Group <br />Dental Prepayment Contrac <br />