Common use of Subject to payment of the Annual Deductible Clause in Contracts

Subject to payment of the Annual Deductible. The following services are limited to one time every 60 months. Endosteal implant. Surgical placement of interim implant body. Eposteal implant. 40% SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Transosteal implant, including hardware. Implant supported complete denture. Implant supported partial denture. Connecting bar implant or abutment supported. Prefabricated abutment. Custom abutment. Abutment supported porcelain ceramic crown. Abutment supported porcelain fused to high noble metal. Abutment supported porcelain fused to predominately base metal crown. Abutment supported porcelain fused to noble metal crown. Abutment supported cast high noble metal crown. Abutment supported cast predominately base metal crown. Abutment supported porcelain/ceramic crown. Implant supported porcelain/ceramic crown. Implant supported crown - porcelain fused to high noble alloys. Implant supported crown - high noble alloys. Abutment supported retainer for porcelain/ceramic fixed partial denture. Abutment supported retainer for porcelain fused to high noble metal fixed partial denture. Abutment supported retainer for porcelain fused to predominately base metal fixed partial denture. Abutment supported retainer for porcelain fused to noble metal fixed partial denture. Abutment supported retainer for cast high noble metal fixed partial denture. Abutment supported retainer for predominately base metal fixed partial denture. Abutment supported retainer for cast metal fixed partial denture. Implant supported retainer for ceramic fixed partial denture. Implant supported retainer for FPD - porcelain fused to high noble alloys. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Implant supported retainer for metal FPD - high noble alloys. Implant/abutment supported fixed partial denture for completely edentulous arch. Implant/abutment supported fixed partial denture for partially edentulous arch. Implant maintenance procedure. Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure. Implant supported crown - porcelain fused to predominantly base alloys. Implant supported crown - porcelain fused to noble alloys. Implant supported crown - porcelain fused to titanium and titanium alloys. Implant supported crown - predominantly base alloys. Implant supported crown - noble alloys. Implant supported crown - titanium and titanium alloys. Repair implant prosthesis. Replacement of semi - precision or precision attachment. Repair implant abutment. Remove broken implant retaining screw. Abutment supported crown - porcelain fused to titanium and titanium alloys. Implant supported retainer - porcelain fused to predominantly base alloys. Implant supported retainer for FPD - porcelain fused to noble alloys. Implant removal. Debridement peri-implant defect. Debridement and osseous peri-implant defect. Bone graft peri-implant defect. Bone graft implant replacement. Implant/abutment supported interim fixed denture for edentulous arch - mandibular. Implant/abutment supported interim fixed denture for edentulous arch - maxillary. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Implant supported retainer - porcelain fused to titanium and titanium alloys. Implant supported retainer for metal FPD - predominantly base alloys. Implant supported retainer for metal FPD - noble alloys. Implant supported retainer for metal FPD - titanium and titanium alloys. Implant index. Semi-precision abutment - placement. Semi-precision attachment - placement. Abutment supported retainer - porcelain fused to titanium and titanium alloys.

Subject to payment of the Annual Deductible. The following services are limited to one time every 60 months. D6010 - Endosteal implant. D6012 - Surgical placement of interim implant body. D6040 - Eposteal implant. D6050 - Transosteal implant, including hardware. D6064 - Abutment supported cast noble metal crown. D6070 - Abutment supported retainer for porcelain fused to predominately base metal fixed partial denture. D6116 - Implant/Abutment Supported Fixed (Hybrid) Dentures for 1-3 teeth. D6117 - Implant/Abutment Supported Fixed (Hybrid) Dentures for 4 or more teeth. D6093 - Re-cement or re-bond implant/abutment supported fixed partial denture. D6110 - Implant/Abutment Supported Removable Denture for 1-3 teeth. D6111 - Implant/Abutment Supported Removable Denture for 4 or more teeth. D6055 - Connecting bar implant or abutment supported. D6056 - Prefabricated abutment. D6057 - Custom abutment. D6058 - Abutment supported porcelain ceramic crown. D6059 - Abutment supported porcelain fused to high noble metal. D6060 - Abutment supported porcelain fused to predominately base metal crown. D6161 - Abutment supported porcelain fused to noble metal crown. D6062 - Abutment supported cast high noble metal crown. D6063 - Abutment supported cast predominately base metal crown. D6058 - Abutment supported porcelain/ceramic crown. D6065 - Implant supported porcelain/ceramic crown. 40% SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Transosteal implant, including hardware. Implant supported complete denture. Implant supported partial denture. Connecting bar implant or abutment supported. Prefabricated abutment. Custom abutment. Abutment supported porcelain ceramic crown. Abutment supported porcelain fused to high noble metal. Abutment supported porcelain fused to predominately base metal crown. Abutment supported porcelain fused to noble metal crown. Abutment supported cast high noble metal crown. Abutment supported cast predominately base metal crown. Abutment supported porcelain/ceramic crown. Implant supported porcelain/ceramic crown. D6066 - Implant supported crown - porcelain fused to high noble alloys. D6067 - Implant supported crown - high noble alloys. D6068 - Abutment supported retainer for porcelain/ceramic fixed partial denture. D6069 - Abutment supported retainer for porcelain fused to high noble metal fixed partial denture. D6071 - Abutment supported retainer for porcelain fused to predominately base metal fixed partial denture. D6069 - Abutment supported retainer for porcelain fused to noble metal fixed partial denture. D6072 - Abutment supported retainer for cast high noble metal fixed partial denture. D6073 - Abutment supported retainer for predominately base metal fixed partial denture. D6074 - Abutment supported retainer for cast metal fixed partial denture. D6075 - Implant supported retainer for ceramic fixed partial denture. D6099 - Implant supported retainer for FPD - porcelain fused to high noble alloys. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. D6077 - Implant supported retainer for metal FPD - high noble alloys. Implant/abutment supported fixed partial denture for completely edentulous arch. Implant/abutment supported fixed partial denture for partially edentulous arch. D6080 - Implant maintenance procedure. D6081 - Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure. D6082 - Implant supported crown - porcelain fused to predominantly base alloys. D6083 - Implant supported crown - porcelain fused to noble alloys. D6084 - Implant supported crown - porcelain fused to titanium and titanium alloys. D6086 - Implant supported crown - predominantly base alloys. D6087 - Implant supported crown - noble alloys. D6088 - Implant supported crown - titanium and titanium alloys. D6090 - Repair implant prosthesis. D6091 - Replacement of semi - precision or precision attachment. D6095 - Repair implant abutment. Remove broken implant retaining screw. Abutment supported crown - porcelain fused to titanium and titanium alloys. Implant supported retainer - porcelain fused to predominantly base alloys. Implant supported retainer for FPD - porcelain fused to noble alloys. Implant removal. Debridement peri-implant defect. Debridement and osseous peri-implant defect. Bone graft peri-implant defect. Bone graft implant replacement. Implant/abutment supported interim fixed denture for edentulous arch - mandibular. Implant/abutment supported interim fixed denture for edentulous arch - maxillary. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. D6096 - Remove broken implant retaining screw. D2753 - Abutment supported crown - porcelain fused to titanium and titanium alloys. D6098 - Implant supported retainer - porcelain fused to predominantly base alloys. D6076 - Implant supported retainer for FPD - porcelain fused to noble alloys. D6100 - Implant removal. D6101 - Debridement peri-implant defect. D6102 - Debridement and osseous peri-implant defect. D6103 - Bone graft peri-implant defect. D6104 - Bone graft implant replacement, covered if implants are covered. D7953 - Bone graft implant replacement. D6110 - Implant/abutment supported removable denture for edentulous arch - maxillary. D6111 - Implant/abutment supported removable dental for edentulous arch - mandibular. D6112 - Implant/abutment supported removable denture for partially edentulous arch - maxillary. D6113 - Implant/abutment supported removable denture for partially edentulous arch - mandibular. D6114 - Implant/abutment supported fixed partial denture for edentulous arch - maxillary. D6118 - Implant/abutment supported fixed partial denture for edentulous arch - mandibular. D6115 - Implant/abutment supported fixed partial denture for partially edentulous arch - maxillary. D6118 - Implant/abutment supported denture for partially edentulous arch - mandibular. D6118 - Implant/abutment supported interim fixed denture for edentulous arch - mandibular. D6119 - Implant/abutment supported interim fixed denture for edentulous arch - maxillary. D6120 - Implant supported retainer - porcelain fused to titanium and titanium alloys. D6121 - Implant supported retainer for metal FPD - predominantly base alloys. D6077 - Implant supported retainer for metal FPD - noble alloys. D6123 - Implant supported retainer for metal FPD - titanium and titanium alloys. D6010-D6117 - Implant index. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. D6190 - Implant index. D6191 - Semi-precision abutment - placement. D6192 - Semi-precision attachment - placement. D6069 - Abutment supported retainer - porcelain fused to titanium and titanium alloys.. The following services are not subject to a frequency limit. D6092 - Re-cement or re-bond implant/abutment supported crown. D6093 - Re-cement or re-bond implant/abutment supported fixed partial denture. 40%

Subject to payment of the Annual Deductible. The following services are limited to one time every 60 months. Endosteal implant. Surgical placement of interim implant body. Eposteal implant. 40% SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Transosteal implant, including hardware. Implant supported complete denture. Implant supported partial denture. Connecting bar implant or abutment supported. Prefabricated abutment. Custom abutment. Abutment supported porcelain ceramic crown. Abutment supported porcelain fused to high noble metal. Abutment supported porcelain fused to predominately base metal crown. Abutment supported porcelain fused to noble metal crown. Abutment supported cast high noble metal crown. Abutment supported cast predominately base metal crown. Abutment supported porcelain/ceramic crown. Implant supported porcelain/ceramic crown. Implant supported crown - porcelain fused to high noble alloys. Implant supported crown - high noble alloys. Abutment supported retainer for porcelain/ceramic fixed partial denture. Abutment supported retainer for porcelain fused to high noble metal fixed partial denture. 40% SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Abutment supported retainer for porcelain fused to predominately base metal fixed partial denture. Abutment supported retainer for porcelain fused to noble metal fixed partial denture. Abutment supported retainer for cast high noble metal fixed partial denture. Abutment supported retainer for predominately base metal fixed partial denture. Abutment supported retainer for cast metal fixed partial denture. Implant supported retainer for ceramic fixed partial denture. Implant supported retainer for FPD - porcelain fused to high noble alloys. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Implant supported retainer for metal FPD - high noble alloys. Implant/abutment supported fixed partial denture for completely edentulous arch. Implant/abutment supported fixed partial denture for partially edentulous arch. Implant maintenance procedure. Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure. Implant supported crown - porcelain fused to predominantly base alloys. Implant supported crown - porcelain fused to noble alloys. Implant supported crown - porcelain fused to titanium and titanium alloys. Implant supported crown - predominantly base alloys. Implant supported crown - noble alloys. Implant supported crown - titanium and titanium alloys. Repair implant prosthesis. Replacement of semi - precision or precision attachment. Repair implant abutment. Remove broken implant retaining screw. Abutment supported crown - porcelain fused to titanium and titanium alloys. Implant supported retainer - porcelain fused to predominantly base alloys. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Implant supported retainer for FPD - porcelain fused to noble alloys. Implant removal. Debridement peri-implant defect. Debridement and osseous peri-implant defect. Bone graft peri-implant defect. Bone graft implant replacement. Implant/abutment supported interim fixed denture for edentulous arch - mandibular. Implant/abutment supported interim fixed denture for edentulous arch - maxillary. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Implant supported retainer - porcelain fused to titanium and titanium alloys. Implant supported retainer for metal FPD - predominantly base alloys. Implant supported retainer for metal FPD - noble alloys. Implant supported retainer for metal FPD - titanium and titanium alloys. Implant index. Semi-precision abutment - placement. Semi-precision attachment - placement. Abutment supported retainer - porcelain fused to titanium and titanium alloys.

Subject to payment of the Annual Deductible. The following services are limited to one time every 60 months. Endosteal implant. Surgical placement of interim implant body. Eposteal implant. Transosteal implant, including hardware. 40% SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Transosteal implant, including hardware. Implant supported complete denture. Implant supported partial denture. Connecting bar implant or abutment supported. Prefabricated abutment. Custom abutment. Abutment supported porcelain ceramic crown. Abutment supported porcelain fused to high noble metal. Abutment supported porcelain fused to predominately base metal crown. Abutment supported porcelain fused to noble metal crown. Abutment supported cast high noble metal crown. Abutment supported cast predominately base metal crown. Abutment supported porcelain/ceramic crown. Implant supported porcelain/ceramic crown. Implant supported crown - porcelain fused to high noble alloys. Implant supported crown - high noble alloys. Abutment supported retainer for porcelain/ceramic fixed partial denture. Abutment supported retainer for porcelain fused to high noble metal fixed partial denture. Abutment supported retainer for porcelain fused to predominately base metal fixed partial denture. Abutment supported retainer for porcelain fused to noble metal fixed partial denture. Abutment supported retainer for cast high noble metal fixed partial denture. Abutment supported retainer for predominately base metal fixed partial denture. Abutment supported retainer for cast metal fixed partial denture. Implant supported retainer for ceramic fixed partial denture. Implant supported retainer for FPD - porcelain fused to high noble alloys. Implant supported retainer for metal FPD - high noble alloys. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Implant supported retainer for metal FPD - high noble alloys. Implant/abutment supported fixed partial denture for completely edentulous arch. Implant/abutment supported fixed partial denture for partially edentulous arch. Implant maintenance procedure. Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure. Implant supported crown - porcelain fused to predominantly base alloys. Implant supported crown - porcelain fused to noble alloys. Implant supported crown - porcelain fused to titanium and titanium alloys. Implant supported crown - predominantly base alloys. Implant supported crown - noble alloys. Implant supported crown - titanium and titanium alloys. Repair implant prosthesis. Replacement of semi - precision or precision attachment. Repair implant abutment. Remove broken implant retaining screw. Abutment supported crown - porcelain fused to titanium and titanium alloys. Implant supported retainer - porcelain fused to predominantly base alloys. Implant supported retainer for FPD - porcelain fused to noble alloys. Implant removal. Debridement peri-implant defect. Debridement and osseous peri-implant defect. Bone graft peri-implant defect. Bone graft implant replacement. Implant/abutment supported interim fixed denture for edentulous arch - mandibular. Implant/abutment supported interim fixed denture for edentulous arch - maxillary. Implant supported retainer - porcelain fused to titanium and titanium alloys. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Implant supported retainer - porcelain fused to titanium and titanium alloys. Implant supported retainer for metal FPD - predominantly base alloys. Implant supported retainer for metal FPD - noble alloys. Implant supported retainer for metal FPD - titanium and titanium alloys. Implant index. Semi-precision abutment - placement. Semi-precision attachment - placement. Abutment supported retainer - porcelain fused to titanium and titanium alloys.