Deductible (Single / Family) $25 / $50 Annual Plan Maximum $1,250 Preventive Services 80% Covered Exams, Cleanings, Fluoride, X-Rays Basic Services 80% Covered Fillings, Extractions, Endodontics, Crown Repairs Major Services 80% Covered Crowns, Dentures, In/Outlays, Periodontics Orthodontia Services 60% Covered Children up to age 19 Orthodontia Lifetime Maximum $1,200