DN-ONECLK-LG Benefit Summary One Click 2024-10-15_5655036_0001_0001 _Dental_31 payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and other limits applicable at time of payment. 1. The Reasonable and Customary charge is based on the lowest of the: "Actual Charge" (the dentist’s actual charge); or "Usual Charge" (the dentist’s usual charge for the same or similar services); or "Customary Charge" (the 90th percentile charge of most dentists in the same geographic area for the same or similar services as determined by MetLife). The service categories and plan limitations shown above represent an overview of your plan benefits. This document presents the majority of services within each category, but is not a complete description of the plan. Page 3 of 3 200 Park Ave., New York, NY 10166 © 2023 MetLife Services and Solutions, LLC L0522023151[exp0525][All States]