Dental Benefits

Calendar Year Maximum (Class I, II, III Expenses)

$1,500 (Class I Applies)

$1,500 (Class I Applies)

Calendar Year Deductible (per Individual/per Family)

$50 / $150

$50 / $150

Class I Expenses - Preventive & Diagnostic Care

Oral Exams, Cleanings, Routine X-rays, Fluoride
Application, Sealants, Space Maintainers (limited to
non-orthodontic treatment),
No Routine X-rays, Emergency care to relieve pain
(administrated at In-Network coinsurance)

100%

No Deductible

100%

No Deductible

Class II Expenses - Basic Restorative Care

Fillings, Oral Surgery - Simple Extractions, Oral Surgery
- all Except Simple Extrations, Surgical Extraction of
Impacted Teeth, Anesthetics,
Minor Periodontics, Major Periodontics, Root
Canal Therapy/Endodontics, Relines, Rebses, and
Adjustments, Repairs-Bridges, Crowns, and Inlays,
Repairs-Dentures, Brush Biopsy

90%

No Deductible

80%

No Deductible

Class III Expenses - Major Restorative Care

Crowns/Inlays/Onlays, Stainless Steel/Resin Crowns,
Dentures, Bridges

60%

No Deductible

50%

No Deductible

Class IV Expenses - Orthodontia

Coverage for Eligible Children and Adults
Lifetime Maximum

50%, No Ortho Deductible
$1,500

50%, No Ortho Deductible
$1,500

Employee

$10.00

$31.52

Employee + Spouse

$40.73

$62.25

Employee + Child(ren)

$63.53

$85.05

Family

$106.48

$128.00