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Class I - Preventive (exams, cleanings, x-rays, etc.)
100% †
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Class II - Basic (fillings, repairs, etc.)
85% †
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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)
80% †
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Deductible
None
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Primary Care Maximum
$3,500
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Orthodontic Maximum (Lifetime)
$1800 up to age 19, $1,200 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.
