Benefit

In Network

Out of Network

Maximum Paid Per Year

$1,500

$1,500

Annual Deductible

None

None

Class I Services
Diagnostic, Preventative

70% - 100% (Increases 10% if dentist is visited once each year)

50% - 80% (Increases 10% if dentist is visited once each year)

Class II Services
Encodontic, Oral Surgery, Restorative, Periodic Services

70% - 100% (Increases 10% if dentist is visited once each year)

50% - 80% (Increases 10% if dentist is visited once each year)

Class III Services
Gold Fillings, Crowns, Inlays when necessary for restoration

50%

50%

Class IV Services
Dentures, Bridges, Partials, Prosthodontics

50%

50%

Orthodontia

80% to $1,000 lifetime maximum per family member

80% to $1,000 lifetime maximum per family member