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Class I - Preventive (exams, cleanings, x-rays, etc.)
100%†
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Class II - Basic (fillings, repairs, etc.)
90%†
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Class III - Major (bridge, dentures, root canals, oral surgery, etc)
80%†
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Class IV - Specialty Care (oral surgery, endodontics, periodontics, pedodontics)
50%†
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Deductible
None
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Primary Care Maxiumum
$1,200
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Specialty Care Maximum
$800
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Orthodontic Maximum (Lifetime)
$1,800 Up to age 19, $1,200 Adults 19+ Comprehensive Case Only
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2025 Schedule of Benefits
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Provider Directory
† PERCENTAGES are APPROXIMATE, see co-payments as listed on the Schedule of Benefits and Fixed Co-Pays.