Deductible (Single/Family) $50 / $100 $50 / $100 $50 / $100 Annual Plan Maximum $1,250 $1,250 $1,250 Preventive Services Exams, Cleanings, Fluoride, X-Rays You Pay 0% You Pay 0% You Pay 0% Basic Services Fillings, Extractions, Endodontics, Crown Repairs You Pay 20% You Pay 20% You Pay 20% Major Services Crowns, Dentures, In/Outlays, Bridges, Implants You Pay 50% You Pay 50% You Pay 50% Orthodontia Services You Pay 50% You Pay 50% You Pay 50% Orthodontia Lifetime Maximum $1,000 $1,000 $1,000 OUT-OF-NETWORK PPO PREMIER