-
Class I - Diagnostic and Preventive (exams, cleanings, x-rays, etc.)
100% †
-
Class II - Restorative (fillings, repairs, etc.)
75% †
-
Class III - Prosthetic (crowns, bridges, partial and complete dentures)
70% †
-
Class IV - Specialty Care (oral surgery, endodontics, periodontic, pedodontics)
50%
-
Deductible
None
-
Primary Care Maxiumum
$1,500
-
Specialty Care Maxiumum
$500
-
Orthodontic Maximum (Lifetime)
$1800 up to age 19, $1200 adults 19+ (comprehensive cases only)
-
2025 Schedule of Benefits and Fixed Copays
-
Provider Directory
† PERCENTAGES are APPROXIMATE, see co-payments as listed on the Schedule of Benefits and Fixed Co-Pays.
