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Class I - Preventive (exams, cleanings, x-rays, etc.)
100%†
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Class II - Basic (fillings, repairs, etc.)
80%†
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Class III - Major (bridge, dentures, root canals, oral surgery, etc)
70%†
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Class IV - Orthodontics
$1,200 Up to age 19, $1,800 Adults 19+ Comprehensive Case Only
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Specialty
50%
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Deductible
None
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Primary Care Maximum
$2,500
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Specialty Care Maximum
$800
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Total Annual Maximum
$3,300
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Schedule of Benefits 2024
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Provider Directory
