In-Network*	Out-of Network**
Annual maximum per person (does not apply to orthodontia)	$1000
Annual deductible	$50 per person $150 per family	$125 per person
Diagnostic and preventive care
Preventive care, examinations, x-rays, oral hygiene & teeth cleaning Fluoride treatments (to age 19) Space maintainers	100% coverage (deductible does not apply)	50% coverage (deducible does not apply)
Restorative care and prosthetics	After deductible	After deductible
Fillings (customary restorative materials) Sealants Oral surgery Periodontics (gum disease therapy) Endodontics (root canal therapy) Inlays and overlays Restorative crowns Fixed and removable bridgework Full or partial dentures Denture relines or rebases	60% 60% 60% 60% 60% 60% 60% 50% 50% 50%	50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
Orthodontics $2,400 Lifetime maximum (does not start over if you change dental plans)	50% (deductible does not apply) Coverage is limited to dependents under age 19	50% (deductible does not apply) Coverage is limited to dependents under age 19

*In-network-When care is provided by or arranged by a HealthPartners dentist
**Out-of-network-When care is provided by a non-network dentist, benefits are paid based on a fair and reasonable fee
schedule. For any care over $300, a predetermination of benefits is neccessary

Emergency services are provided to the same extent as eligible dental services specified above and subject to the same copayment percentages, deductibles and maximums.