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| Benefit Name | Individual | Family |
|---|---|---|
| Deductible Amount | $2,000 | $4,000 |
| Coinsurance Factor | 20% | 20% |
| Coinsurance Amount | $2,500 | $5,000 |
| Maximum Benefit Amount | $7,000 | $15,000 |
| Professional Fee Allowable Amount | N/A | N/A |
| Professional Fee Visit Limit Per Year | N/A | N/A |
| Office Visit Allowable Amount | $45 | N/A |
| Office Visit Maximum Benefit Amount | $450 | $900 |
| Office Visits Per Year | 10 | 20 |
| Copay Amount | N/A | N/A |
| Pediatric Dental Benefit Amount | $1,000 | $1,000 |