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CALENDAR YEAR MAXIMUMS, DEDUCTIBLES
Annual Maximum:
$2,500 per individual
Annual Deductible:
$50 individual/$150 family
(excluding diagnostic & preventive)
Orthodontics:
$2500 lifetime maximum benefit per individual

Patient Treatment Plan Schedule of Allowances & Co-Pays Permissible Charges Maximums, Deductibles Limitations, Exclusions Coordination of Benefits Claim Form Addresses & Phone Numbers Contact