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| OFFICE VISIT |
$5.00 |
$10.00 |
CLASS I
Preventative |
100% |
100% (exams)
50% |
CLASS II
Basic Restorative |
75% |
50% |
CLASS III
Prosthetic |
50% |
50% |
CLASS IV
Specialty Care |
50% |
50%
Pedodontics NCB |
|
CLASS V
Orthodontics
LIFETIME MAXIMUM
|
$1,500.00
(up to age 19)
$ 750.00
(Subscriber/Spouse) |
$1,200.00
(up to age 19)
$ 500.00
(Subscriber/Spouse) |
Annual Maximum
Per Family Member |
$1,200.00 |
$ 800.00 |
| Plan Annual Premiums |
$268.80 (Single)
$406.68 (Family of 2)
$548.04 (Family) |
$205.08 (Single)
$279.24 (Family of 2)
$368.76 (Family) |