-
Class I - Preventive (exams, cleanings, x-rays, etc.)
70%†
-
Class II - Basic (fillings, repairs, etc.)
50%†
-
Class III - Major (bridge, dentures, root canals, oral surgery, etc)
50%†
-
Class IV - Specialty Care (oral surgery, endodontics,periodontics,pedodontics)
30%†
-
Deductible
None
-
Combined Primary and Specialty Care Max
$1,200
-
Orthodontic Maximum (Lifetime)
$500 for Dependents up to age 19 (Comprehensive Case Only)
-
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.
