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Understanding Dental Insurance
 
Is dental insurance a good thing?

Yes! Insurance has helped millions to achieve a higher level of dental health. But it must be used correctly. Some people believe that if they don’t have insurance that they can’t afford dental work. Some people with insurance believe that if their insurance won’t pay for dental procedures, then they must not need it, or they believe it isn’t important. Others won’t spend beyond its limitations.
THE TRUTH is that dental insurance provides help with getting dental work you would do anyway (you just budget differently). Not having insurance doesn’t make your teeth less important or necessary for health, social/career success, or self-confidence. Besides, you only get a limited amount of coverage anyway! Dental insurance is a good thing if you don’t let the insurance company make your health decisions for you, or think that without it you can’t afford dental care.


What is dental insurance?
Insurance is a way of controlling risk and protecting yourself against a financial loss by spreading the risk of loss across a large population. Common examples include auto, home and life insurance. Premium rates and costs are determined by adding up the calculated costs of benefits paid out, plus overhead and administrative costs, plus the profits desired by the insurance company. Like any other insurance, better benefits are obtained by paying higher premiums.


What will my dental insurance cover?
Unlike major medical, there is no such thing as “major dental”. Few, if any dental insurance plans are a “pay-all”. Some insurance companies pay a fixed amount, others a percentage of pre-determined limits. Any plans that claim to or actually do pay the entire dental bill can only do so because of agreements or choices that discount services, or offer low quality or cheaper treatment.


What dental services are covered? What aren’t?
Like any other insurance, your insurance coverage is only as good as the policy that was purchased. Many people are surprised to discover that many dental services are not covered. If you are dissatisfied with the amount or limits of your coverage it is important to discuss this with your employer and insurance company.
In an attempt to decrease their costs, dental insurance companies tend to reward prevention and limit reimbursement for complex or more involved care. In short, while they may pay well for wellness checkups and cleanings, they tend to discourage higher quality services. Higher quality and “major” treatment services may not be covered as well, or at all. The coverage available to you is solely determined by the profit structures of the insurance company and the quality of insurance purchased by you or your employer. Better insurance coverage costs more!


Why won’t my insurance pay more?
Unlike major medical plans which may cover complex treatment and protect against “catastrophic loss”, all dental plans have a “stop-loss” or “Annual Maximum” which typically ranges from $1,000 to $1,500 per year. This means that regardless of your need or situation, the insurance company will not pay out more to you than this annual limit. Thus there is no risk or downside to the insurance company, and it hardens or stabilizes their profits. For you, “dental insurance” equates to nothing more than having “pre-paid dentistry” which you must use or lose each year. Additionally, complex and convoluted rules and formulations for payment of benefits are created and used by your insurance company to deny, delay, and defray the reimbursement of covered services.


Do insurance companies exist to pay for dental care?
There is only one purpose for dental insurance companies – to make a profit. Ironically, while insurance premiums have steadily increased over the past 35 years, the average insurance coverage is still the same as it was 35 years ago when it started - $1000. Inflation alone should certainly have increased the available benefit to over $5,000-10,000 today. Your insurance company gives you increasingly less coverage and charges you more for it. It is why they can pay their CEOs extraordinary salaries and continue to own and acquire real estate and stock market holdings as they do. (Why would they want you to get cheaper dentistry, or deny payment for quality care?)


How does my insurance company make money?
Income minus overhead equals profits! In other words - Your insurance company collects the premiums, administrates the benefits plan, and makes a profit on the difference. Complex rules for annual limits (“stop-loss” maximums), utilization of services, coverage percentages, and UCR fee schedules, aid the insurance company in their quest to take in more money and give out less in the way of benefits. They are typically very slow to adopt modern treatments, they disallow alternative based therapies, they usually disallow coverage for functional based problems and they cover other high quality procedures poorly, and they use their own internal fee schedules (U.C.R. dictated by zip code geography) that are not the same as your dentist’s fee schedule, and which is determined solely on the profit motives of their company.
“Deny, delay, and defer” are watch-words that infamously characterize the insurance industry and frustrate both doctor and patient in trying to be made whole after care is rendered. Pre-authorization and pre-determination rules complicate and hinder the timely and effective delivery of care – all unnecessary and designed to delay and second-guess the doctor-patient relationship and increase the profits of the insurance company. We are all grateful for what insurance can and does afford us. All insurance companies are contractually obligated to pay benefits to which you, their insured, are entitled. The “game” lies in getting there.


Who is responsible for payment?
When you present for care and agree to treatment, you accept direct responsibility for paying the dental bill to the dentist, regardless of third-party coverage or assignment of benefits. Remember that your dentist works for you, not your insurance company. Our staff will assist you in filing insurance claim forms, but we can’t guarantee any estimated coverage.


What should I do if I don’t have insurance, or run out of insurance coverage?
Approximately 60% of our population does not have dental insurance coverage. When it comes to their own dental needs, they simply budget their discretionary dollars so as to afford dental care. If needed care exceeds your insurance coverage (a very likely scenario) you will do the same.
It is more about what you value than the amount of money available. Proof exists in the fact that we buy cars or boats, go on vacations and travel, buy pet food, cosmetics and hair care, do recreation and dinner out (and not always at the cheapest restaurant), tobacco, alcohol, etc. – in essence, have a lifestyle – all without using insurance reimbursement to fund it. The truth is that little if any of this “lifestyle” spending is “necessary!” It is all discretionary! Unlike heart attacks and broken legs, almost all of dentistry is discretionary as well. (How many broken smiles have you seen lately?) The key is to understand and change your values, to make better discretionary spending choices, and to make it affordable with financial options - before you suffer irreparable damage.


Should I use my insurance coverage to determine my dental treatment?
In a word – “No!” It is understandable that you might want to make treatment decisions based on how much coverage you have. You may even assume that your coverage will pay for all of your costs. Regrettably, this is not the case! Just as you would never choose to leave portions of your cancer untreated, you shouldn’t choose to ignore dental decay, broken teeth, toothaches, abscessed teeth, and maybe even unattractive unflattering smiles that hurt you socially or in your career. This would be true whether you had or didn’t have third-party coverage, or had limitations of coverage therein. Your insurance company doesn’t care if you have disease or ugly! Their primary interest is not you. It is in protecting the difference between their income and their outgo. Period!


What does it mean when my insurance company tells me my dentist’s fees “exceed usual, customary and reasonable”? What is “UCR”?
It usually means that your insurance benefits are too low. Better insurance plans will often pay a higher amount. With dental insurance, you get what you and your employer pay for minus the overhead and profits of the insurance company.
“UCR” stands for Usual Customary and Reasonable. The insurance industry uses this term to try to standardize fees and to make a commodity out of professional services. They would have you believe that a dentist is a dentist is a dentist, and a crown is a crown is a crown, regardless of the training, care, skill and judgment required to accomplish it. There is no UCR fee that truly represents “usual, customary or reasonable” that isn’t created internally by the insurance company based upon its own internal overhead and profit calculations.


Will my dental insurance pay for my dental care?
Yes – up to a point. And that point is determined by the limitations and exclusions in your insurance policy, and the type of plan it is.


Why does my insurance company not pay for some procedures?
The determination of whether certain procedures are covered or not is dependant on what type of policy and how much your employer pays for it. Typically, insurance will not pay for “elective” or “functional” problems that do not have their basis in trauma or pathology. Some modern dentistry and newer cosmetic procedures are likewise not covered. The purpose of dental insurance is not to be a pay-all or make you look beautiful, but to help defray the expenses associated with prevention and minor reparative work.


What is the relationship between dental fees and insurance coverage?
When an insurance company policy states it will pay X % of a procedure, it is using its own fee schedule, not the dentists. Usually insurance companies fee schedules are lower than the dentists. These fee schedules are internal to the insurance company, are determined solely by the overhead and profit motives of the insurance company, and have no relationship with the actual fees charged by the dentist. Additionally, these fee schedules will vary from area to area, despite the uniformity of the standard-of-care in our country. Insurance companies would have you believe that you can get something for nothing.


What’s the best way to deal with problems related to my dental health benefits?
You are best advised to discuss issues that may arise with your employer or his human resources manager, and/or your labor union. Remember that the “richness” of your benefits package is determined by how much is paid for the insurance policy in the first place, as well as the internal policy rules that regulate the ease and availability of getting the benefits paid out.


What are the different kinds of insurance plans?

There are three main types of insurance:

1. Traditional indemnity insurance plans
2. Preferred provider organizations (PPO)
3. Health maintenance organizations (HMO)

Traditional indemnity plans offer the greatest freedom of choice in services and health care providers. PPOs and HMOs, sometimes referred to as “alphabet” and “managed care” plans, frequently result in less freedom of choice for the patient , fewer available appointments, cheaper dental materials and lab quality, and have more restrictions and exclusions in what they cover.


Do I have to go where my insurance company says? Am I required to see a certain dentist?
No! But if you have a closed or restricted plan, you may not receive the meager benefits purchased unless you see their preferred doctors who have agreed to discount their services and who offer cheaper care. If you have one of these plans and if you decide you want better care for yourself or your family than what your insurance policy will pay for, you are always free to choose higher levels of services and higher quality of care from private fee-for-service offices such as The Center For Dental Health. Traditional indemnity insurance plans are representative of the better plans and do not have prohibitions or restrictions on who you may or may not see.


 

Free Health Insurance Quote offered through Affiliate Program at Alabama, Alaska, Arizona, Arkansas, Connecticut, Delaware, District of Columbia (Washington DC), Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

Individual Health Plan of California
Aetna PPO 500
Aetna PPO 1500
Aetna PPO 2500
Aetna PPO 5000
Aetna PPO HSA 1
Aetna PPO HSA 2
Aetna PPO Value 1500
Aetna PPO Value 2500
Aetna PPO Value 5000

Blue Cross Tonik 1500

Blue Cross Tonik 5000

Blue Cross Tonik 3000
Blue Cross Basic PPO 2500
Blue Cross Basic PPO 1000
Blue Cross PPO 3500
Blue Cross PPO 3500 HSA
Blue Cross PPO Share 5000
Blue Cross PPO Saver
Blue Cross PPO Share 2500
Blue Cross PPO Share 1500
Blue Cross PPO Share 1000
Blue Cross PPO Share 500
Blue Cross EPO (HSA Compatible)
Blue Cross HMO Saver
Blue Cross HMO 100
BC Select HMO BC Select HMO
BC Right Plan Right Plan - No Rx
BC Right Plan Right Plan - Generic Rx
BC Right Plan Right Plan - Full Rx
BC Tonik Tonic 1500
BC Tonik Tonic 3000
BC Tonik Tonic 5000
Blue Shield Shield Spectrum PPO 500
Blue Shield Shield Spectrum PPO 750
Blue Shield Shield Spectrum PPO 1500
Blue Shield Shield Spectrum PPO 2000
Blue Shield Shield Spectrum PPO 5000
Blue Shield Spectrum PPO Savings 2400
Blue Shield Spectrum PPO Savings 4000
Blue Shield Access+ HMO
Blue Shield Access+ Value HMO
BS Subscriber Only Active Start 35
BS Subscriber Only Active Start 25
BS Subscriber Only Essential 3000
BS Subscriber Only Essential 3000
Health Net HMO 15
Health Net HMO 40
Health Net SmartChoice HSA 2500
Health Net SimpleChoice HSA 4000
Health Net FirstChoice PPO
Health Net SimpleChoice 50
Health Net SimpleChoice 40
Health Net SimpleChoice 35
Health Net SimpleChoice 25
Health Net SimpleChoice 15
Health Net VB Value Choice 1500
Health Net VB SimpleValue 50
Health Net VB SimpleValue 50 Rx
Health Net VB SimpleValue 40
Health Net VB SimpleValue 40 Rx
Health Net VB SimpleValue 30
Health Net VB SimpleValue 30 Rx
Nationwide PPO 25 $750 Ded
Nationwide PPO 25 $1500 Ded
Nationwide PPO 25 $2500 Ded
Nationwide Lifestyle 1750 Gen Rx
Nationwide Lifestyle 1750
Nationwide Lifestyle 2500 Gen Rx
Nationwide Lifestyle 2500
Nationwide Lifestyle 3500 Gen Rx
Nationwide Lifestyle 3500
Nationwide Lifestyle 4500 Gen Rx
Nationwide Lifestyle 4500
Pacificare HMO 10-35/250
Pacificare HMO 20-35/80
Pacificare HMO 35/70
Pacificare HMO 35/50
Pacificare PPO 70/50/500
Pacificare PPO 70/50/1000
Pacificare PPO 70/50/2000
Pacificare PPO 60/50/2500
Pacificare PPO 70/50/3000
Pacificare PPO 70/50/5000
Pacificare PPO HSA 2700
Pacificare PPO HSA 5000
Pacificare PPO 70/50/3000 SD
Pacificare PPO 70/50/5000 SD
Pacificare PPO 70/50/1000 Maternity
Pacificare PPO 70/50/1500 MaternityAetna HMO Plan 10-30
Aetna HMO Plan 20-40
Aetna HMO Plan 30-40
Aetna EPO 90
Aetna EPO 80
Aetna Basic PPO
Aetna MC Zero 90/60 PPO
Aetna MC $250 90/70 PPO
Aetna MC $500 90/70 PPO
Aetna MC $250 80/60 PPO
Aetna MC $500 80/60 PPO
Aetna mc $500 80/50 PPO
Aetna MC $1000 80/50 PPO
Aetna MC $2000 80/50 PPO
Aetna HSA 2100
Aetna HSA 3000
Aetna Value HMO Value HMO 25-40
Aetna Value HMO Value HMO 15-30
Aetna Value HMO Value HMO 10-20
Blue Cross Saver HMO
Blue Cross Classic HMO
Blue Cross HMO 100
Blue Cross Basic PPO
Blue Cross Hospital BeneFits
Blue Cross Hospital BeneFits Plus
Blue Cross Hospital BeneFits Pref
Blue Cross High Deductible EPO
Blue Cross Saver PPO
Blue Cross PPO 40
Blue Cross PPO 30
Blue Cross PPO 35 GenRx
Blue Cross Power Fund 750
Blue Cross Power Fund 500
Blue Cross Advantage 25 PPO
Blue Cross Premier 20 PPO
Blue Cross Premier 10 PPO
Blue Cross PPO 2400
Blue Cross PPO 3500
Blue Cross PS HMO Power Select HMO Plan
Blue Shield Access+ HMO 5
Blue Shield Access+ HMO 10
Blue Shield Access+ HMO 15
Blue Shield Access+ HMO 20
Blue Shield Access+ H00025
Blue Shield Access+ HMO 40
Blue Shield Added Advantage POS 300
Blue Shield Pref Sav $1250 Ded
Blue Shield Pref Sav $2250 Ded
Blue Shield Pref Sav $2600 Ded
Blue Shield Spectrum PPO Zero Deductible
Blue Shield Spectrum PPO 250 Premier
Blue Shield Spectrum PPO 250 Standard
Blue Shield Spectrum PPO 500 Value
Blue Shield Spectrum PPO 500 Standard
Blue Shield Spectrum PPO 500 Premier
Blue Shield Spectrum PPO 1000
Blue Shield Spectrum PPO 3000
Blue Shield Active Choice 500
Blue Shield Active Choice 750
Health Net HMO 10
Health Net HMO 15
Health Net HMO 20
Health Net HMO 30
Health Net HMO 35
Health Net HMO 40
Health Net HMO Xtra Value 20
Health Net HMO Xtra Value 40
Health Net Variable Hosp Copay HMO 25
Health Net Variable Hosp Copay HMO 35
Health Net Elect Open Acces 30
Health Net Elect Open Access 25
Health Net Elect Open Access 20
Health Net Elect Open Access 10
Health Net Select 30 POS
Health Net Select 20 POS
Health Net Sel Prem 10 POS
Health Net Saver PPO
Health Net PPO 40
Health Net PPO 35
Health Net PPO 30
Health Net PPO 25
Health Net PPO 20
Health Net PPO 15
Health Net PPO 10
Health Net HSA 2000
Health Net HSA 3000
Health Net Silver HMO 20 Silver
Health Net Silver HMO 40 Silver
Health Net Silver HMO Xtra Value 20 Silver
Health Net Silver HMO Xtra Value 40 Silver
Health Net Salud Salud HMO
Health Net Salud Salud PPO
Kaiser HMO Ded 30/1000
Kaiser HMO Ded 30/1500
Kaiser HMO Plan 5
Kaiser HMO Plan 15
Kaiser HMO Plan 20
Kaiser HMO Plan 30
Kaiser HMO Plan 50
Kaiser Point of Service Plan
Nationwide Plan 1
Nationwide Plan 2
Nationwide Plan 3
Nationwide Plan 4
Nationwide Plan 5
Nationwide Plan 6
PacifiCare HMO 10
PacifiCare HMO 15
PacifiCare HMO 10/500d
PacifiCare HMO 20
PacifiCare HMO 35/600d
PacifiCare POS 15/80-60
PacifiCare PPO 80/60-250
PacifiCare PPO 70/50-250
PacifiCare PPO 80/60-500
PacifiCare PPO 70/50-1000
PacifiCare PPO 35-50/50-1000
PacifiCare PPO 70/50-2000
PacifiCare PPO 70/50-3500
PacifiCare PPO 80/50-2000/freedom
PacifiCare PPO 70/50-2000/freedom
PacifiCare PPO 50/50-3000/freedom
PacifiCare PPO HSA 2700
PacifiCare PPO HSA 3500
PacifiCare PPO HSA 5000
Pacificare Adv HMO HMO 10/500d
Pacificare Adv HMO HMO 35/600d
Sharp Health Plan HMO Plan A
Sharp Health Plan HMO Plan AB
Sharp Health Plan HMO Plan C
Sharp Health Plan HMO Plan AD

Sharp Health Plan HMO Plan AE
Western Health Adv HMO Premier 5
Western Health Adv HMO Premier 10
Western Health Adv HMO Premier 15
Western Health Adv HMO Premier 20
Western Health Adv HMO Advantage 15-30
Western Health Adv HMO Advantage 420
Western Health Adv HMO Advantage 70
Western Health Adv HMO Advantage 30-40
Western Health Adv HMO Advantage 40
Western Health Adv HMO Deductible 1000

Health Insurance Companies by State

Dental Alaska
Celtic Ins. Co.
Golden Rule

Dental Alabama
Celtic Ins. Co.
Time Insurance Company
Golden Rule
Arkansas
Celtic Ins. Co.
Golden Rule
American Medical Security Life Insurance Company
Arkansas Blue Cross and Blue Shield
Arizona
Health Net of Arizona
Celtic Ins. Co.
Golden Rule
PacifiCare of Arizona
Time Insurance Company
American Medical Security Life Insurance Company
Humana
Aetna
CIGNA
LifeWise Health Plan of Arizona

Dental California
Blue Shield of California
Blue Cross of California
PacifiCare
Health Net
Kaiser Permanente of CA
Time Insurance Company
Aetna

Dental Colorado
Kaiser Permanente
American Medical Security Life Insurance Company
Anthem BlueCross BlueShield
Celtic Ins. Co.
Golden Rule
PacifiCare
Humana

Dental Connecticut
Celtic Ins. Co.
Golden Rule
Anthem Blue Cross and Blue Shield of CT
Aetna

Dental Dist. of Columbia
Celtic Ins. Co.
CareFirst BlueCross BlueShield
Aetna
Time Insurance Company
Kaiser Mid-Atlantic

Dental Delaware
Golden Rule
American Medical Security Life Insurance Company
Celtic Ins. Co.
Aetna

Dental Florida
Golden Rule
Celtic Ins. Co.
Time Insurance Company
Vista Healthplan of South Florida
Humana
Aetna

Dental Georgia
Kaiser Permanente
Celtic Ins. Co.
Golden Rule
Blue Cross Blue Shield of Georgia
Humana
Time Insurance Company
Aetna

Hawaii
Kaiser Permanente of HI

Iowa
Celtic Ins. Co.
American Medical Security Life Insurance Company
Golden Rule

Idaho
Blue Cross of Idaho
Time Insurance Company
Regence BlueShield

Illinois
Celtic Ins. Co.
UNICARE
Golden Rule
BlueCross BlueShield of Illinois
American Medical Security Life Insurance Company
Humana
Time Insurance Company
Aetna

Indiana
Anthem Blue Cross and Blue Shield
UNICARE
Golden Rule
Celtic Ins. Co.

Kansas
BlueCross BlueShield of Kansas City
Celtic Ins. Co.
Humana

Kentucky
Anthem Blue Cross and Blue Shield
Humana
Golden Rule

Louisiana
Celtic Ins. Co.
Time Insurance Company
Humana
BlueCross BlueShield of Louisiana

Maryland
CareFirst BlueCross BlueShield
Golden Rule
Aetna
Kaiser Mid-Atlantic

Michigan
American Medical Security Life Insurance Company
Celtic Ins. Co.
Golden Rule
Time Insurance Company
Blue Cross Blue Shield of Michigan
Humana
UNICARE

Minnesota
Blue Cross and Blue Shield of Minnesota
HealthPartners
Medica of Minnesota

Missouri
Blue Cross Blue Shield of Missouri
American Medical Security Life Insurance Company
Golden Rule
Celtic Ins. Co.
BlueCross BlueShield of Kansas City
Humana

Mississippi
Celtic Ins. Co.
Golden Rule

Montana
Celtic Ins. Co.
Time Insurance Company
BlueCross BlueShield of Montana

North Carolina
American Medical Security Life Insurance Company
Celtic Ins. Co.
Time Insurance Company

North Dakota
Time Insurance Company

Nebraska
BlueCross BlueShield of Nebraska
Celtic Ins. Co.
Golden Rule
American Medical Security Life Insurance Company

New Hampshire
Celtic Ins. Co.

New Jersey
Horizon Blue Cross Blue Shield of New Jersey
Oxford Health Plans, Inc.

New Mexico
American Medical Security Life Insurance Company
Celtic Ins. Co.
Blue Cross Blue Shield of New Mexico

Nevada
Anthem BlueCross BlueShield
Health Plan of Nevada
Celtic Ins. Co.
PacifiCare of Nevada

New York
Group Health Incorporated

Ohio
Anthem Blue Cross and Blue Shield
Celtic Ins. Co.
Golden Rule
American Medical Security Life Insurance Company
Kaiser Permanente of Ohio
Medical Mutual
Humana
Time Insurance Company
Aetna
HealthAmerica

Oklahoma
Celtic Ins. Co.
Golden Rule
American Medical Security Life Insurance Company

Oregon
Regence BlueCross BlueShield of Oregon
Health Net of Oregon
LifeWise Health Plan of Oregon
Kaiser Permanente
PacifiCare of Oregon

Pennsylvania
Celtic Ins. Co.
Golden Rule
American Medical Security Life Insurance Company
Time Insurance Company
Aetna
HealthAmerica

South Carolina
Celtic Ins. Co.
Blue Cross and Blue Shield of South Carolina
Golden Rule

South Dakota
Celtic Ins. Co.
Medica

Tennessee
American Medical Security Life Insurance Company
Golden Rule
BlueCross BlueShield of Tennessee
Celtic Ins. Co.
Humana

Texas
Celtic Insurance Company
UNICARE Life & Health Insurance Company
Golden Rule Insurance Company
Time Insurance Company
Blue Cross and Blue Shield of Texas, A Division OF Health Care Service Corporation
Humana Insurance Company
Aetna Life Insurance Company

Utah
Intermountain Health Care
Regence BlueCross BlueShield of Utah
American Medical Security Life Insurance Company

Virginia
Golden Rule
UNICARE
Anthem Blue Cross and Blue Shield
CareFirst BlueCross BlueShield
Aetna
Kaiser Mid-Atlantic

Washington
LifeWise Health Plan of Washington
Group Health Cooperative
Regence BlueShield
Regence BlueCross BlueShield of Oregon

Wisconsin
American Medical Security Life Insurance Company
Celtic Ins. Co.
Golden Rule
Blue Cross Blue Shield of Wisconsin
Humana

Wyoming
Celtic Ins. Co.
Time Insurance Company
Celtic Health Insurance
Golden Rule Health Insurance
Fortis Health Insurance
Vista Health Plan
Time Insurance
Humana
Blue Cross Blue Shield of Florida
Clarendon National (Short Term Health Insurance Only)
(Some plans may not be available in all parts of the state)



 
 
 

 

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