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<br />~-~- <br /> <br />~--- <br /> <br />-- <br />--~- <br /> <br />-~--~-~-- ~ <br /> <br />- -~----- <br /> <br />ARTICLE 4 -- BENEFITS PROVIDED; LIMITATIONS AND EXCLUSIONS <br /> <br />4.1 <br /> <br />4.2 <br /> <br />4.3 <br /> <br />Subject to the limitations and exclusions set forth below, the following <br />services are Benefits when they are provided by a Dentist and when they <br />are necessary and customary as determined by the standards of generally <br />accepted dental practice. <br /> <br />DIAGNOSTIC AND PREVENTIVE BENEFITS. Delta agrees to satisfy <br />80% of the Dentist's Usual, Customary, and Reasonable fees or ofthe Fees <br />Actually Charged, whichever is less, for the following Diagnostic and <br />Preventive Benefits: <br /> <br />Diagnostic - <br /> <br />oral examinations <br />x-rays <br />diagnostic casts <br />biopsy/tissue examination <br />emergency palliative treatment <br />specialist consultation <br /> <br />Preventive - Cleaning (prophylaxis) <br />topical application of fluoride solution <br />space maintainers <br /> <br />LIMITATIONS ON DIAGNOSTIC AND PREVENTIVE BENEFITS: <br /> <br />(a) <br /> <br />An oral examination is a Benefit only when the Dentist has an <br />accepted fee on file with Delta for this procedure. It will not be <br />provided more than twice in a calendar year while the patient is an <br />Eligible Person under any Delta program. <br /> <br />(b) <br /> <br />Cleanings are limited under Section 4. 11 (a). <br /> <br />10 <br /> <br />~ - <br /> <br />~---~ <br /> <br />. ,,~'_""d""_'--"---'~-'---'- <br />