Dental Complete Classic 2ZGE Rates 80%/60%/50% $150 Diagnostic and $1,000 Maximum Allowed Zip Codes: 100-101-102 Low $40.40 $82.42 $103.27 $156.98 N/A $34.59 $70.56 $75.92 $115.39 N/A Zip Codes: 100-101-102 High $44.79 $91.38 $114.50 $174.04 N/A $38.35 $78.23 $84.17 $127.94 N/A Zip Codes: 103-119 Low $36.88 $75.23 $94.27 $143.30 N/A $31.57 $64.40 $69.30 $105.34 N/A Zip Codes: 103-119 High $40.88 $83.40 $104.52 $158.88 N/A $35.00 $71.40 $76.84 $116.79 N/A Diagnostic and Basic Services Major Services o Groups with 2-4 employees require 100% participation. All other occupations are Low Occupations 05770NYBENEBS_2ZGE Rev 09/2017
Dental Complete Classic 2ZGF Rates 100%/80%/50% $50 Diagnostic and $1,500 Maximum Allowed 100%/80%/50% $150 Diagnostic and $1,500 90 th Percentile of Zip Codes: 100-101-102 Low $73.61 $150.17 $188.31 $286.22 N/A $63.02 $128.56 $138.42 $210.40 N/A Zip Codes: 100-101-102 High $81.62 $166.50 $208.78 $317.34 N/A $69.87 $142.53 $153.47 $233.28 N/A Zip Codes: 103-119 Low $60.57 $123.56 $154.93 $235.50 N/A $51.85 $105.77 $133.89 $173.11 N/A Zip Codes: 103-119 High $67.15 $136.99 $171.78 $261.10 N/A $57.49 $117.27 $126.27 $191.93 N/A Diagnostic and Basic Services Major Services - Space maintainers o Groups with 2-4 eligible employees require 100% participation. All other occupations are Low Occupations 05770NYBENEBS_2ZGF Rev 09/2017
Dental Complete Classic 2ZGG Rates 100%/80%/50% $150 Diagnostic and $1,000 90 th Percentile of Zip Codes: 100-101-102 Low $64.01 $130.59 $163.74 $248.89 N/A $54.80 $111.79 $120.37 $182.96 N/A Zip Codes: 100-101-102 High $70.97 $144.78 $181.55 $275.95 N/A $60.76 $123.94 $133.45 $202.85 N/A Zip Codes: 103-119 Low $52.67 $107.44 $134.72 $204.78 N/A $45.09 $91.98 $99.04 $150.53 N/A Zip Codes: 103-119 High $58.39 $119.12 $149.37 $227.04 N/A $49.99 $101.98 $109.80 $166.90 N/A Diagnostic and Basic Services Major Services o Groups with 2-4 employees require 100% participation. All other occupations are Low Occupations 05770NYBENEBS_2ZGG Rev 09/2017
Dental Complete Voluntary 2ZGK Rates 100%/80%/50% $150 Diagnostic and $1,000 90 th Percentile of Zip Codes: 100-101-102 Low $71.00 $144.83 $148.67 $225.90 N/A $58.78 $119.91 $123.04 $187.03 N/A Zip Codes: 100-101-102 High $78.72 $160.58 $164.78 $250.46 N/A $65.17 $132.95 $136.42 $207.36 N/A Zip Codes: 103-119 Low $58.41 $119.17 $122.28 $185.86 N/A $48.36 $98.66 $101.24 $153.88 N/A Zip Codes: 103-119 High $64.77 $132.12 $135.57 $206.07 N/A $53.62 $109.39 $112.24 $170.61 N/A Diagnostic and Basic Services Major Services Voluntary dental sold stand-alone or with medical: A minimum of two eligible employees must enroll in the stand-alone dental products. Twelve month waiting period for voluntary major services (waived if prior comparable coverage). All other occupations are Low Occupations 05770NYBENEBS_2ZGK Rev 09/2017
Dental Complete Voluntary 2ZGL Rates 100%/80%/50% $50 Diagnostic and $1,500 Maximum Allowed 100%/80%/50% $150 Diagnostic and $1,500 90 th Percentile of Zip Codes: 100-101-102 Low $81.65 $166.56 $170.91 $259.78 N/A $67.60 $137.90 $141.50 $215.08 N/A Zip Codes: 100-101-102 High $90.52 $184.67 $189.49 $288.03 N/A $74.95 $152.89 $156.88 $238.46 N/A Zip Codes: 103-119 Low $67.18 $137.04 $140.62 $213.74 N/A $55.62 $113.46 $116.42 $176.96 N/A Zip Codes: 103-119 High $74.48 $151.94 $155.91 $236.98 N/A $61.66 $125.79 $129.08 $196.20 N/A Diagnostic and Basic Services Major Services Voluntary dental sold stand-alone or with medical: A minimum of two eligible employees must enroll in the stand-alone dental products. Twelve month waiting period for voluntary major services (waived if prior comparable coverage). All other occupations are Low Occupations 05770NYBENEBS_2ZGL Rev 09/2017