Annual Plan Maximum $1,500 100% Covered 80% Covered 80% Covered Deductible (Single / Family) $50 / $150 Preventive Services Exams, Cleanings, Fluoride, X-Rays Basic Services Fillings, Extractions, Endodontics, Crown Repairs Major Services Crowns, Dentures, In/Outlays, Periodontics *Usual and customary out of network coverage reimbursable at the 99th percentile