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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 - Specialty Care (when performed at a specialist)
50%
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Primary Care Maximum
$2500
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Specialty Care Max
$800
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Orthodontic Maximum (Lifetime)
$1,800 up to age 19
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Orthodontic Maximum (Lifetime)
$1200 adults 19+, comprehensive case only
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2025 Schedule of Benefits and Fixed Copays
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Provider Directory
† PERCENTAGES are APPROXIMATE, see co-payments as listed on the Schedule of Benefits and Fixed Co-Pays.
