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