THE ABOVE COPAYMENTS DO NOT INCLUDE THE ADDITIONAL COST OF PRECIOUS AND SEMI-PRECIOUS METAL.
All procedures listed may not be performed by the Participating General Dentist you select. The copayments shown apply to those Company Plan Participating General Dentists who do perform those services. Therefore, you are encouraged to discuss availability of the scheduled services with your Participating General Dentist. Procedures not listed on the schedule of bene- fits, that are performed by the selected Participating General Dentist will be charged at that Participating General Dentist's usual and customary fee less 25%.
SPECIALISTS: Should you need a specialist (i.e., Endondontist, Oral Surgeon, Periodontist, Prosthodontist, Pediatric Dentist), you may be referred by your Participating General Dentist. Copayment amounts are applicable when treatment is performed by selected Participating General Dentist or by Participating Specialists. Benefits for procedures not listed on the schedule of benefits, that are performed by a Participating Specialist are available at the Participating Specialist's usual and customary fee less 25%.
NOTE: When crown and/or bridgework exceeds six consecutive units, the patient may be charged an additional $25.00 per unit.
* Plus laboratory fees when applicable
