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| MONTHLY | PREVENTIVE DENTAL |
| Employee Only | $27 |
| Employee + Spouse | $43 |
| Employee + Child(ren) | $42 |
| Family | $62 |
| In-Network | Out-of-Network |
|
Preventive & Diagnostic Exams; Cleanings; Bitewing X-Rays; Full Mouth X-Rays; Fluoride Treat- |
Covered at 100% |
|
Annual Maximum (per person) |
$1,000 |
|
Annual Deductible Per Person |
None |
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