| Dental Plan | High Plan | Low Plan | |
|---|---|---|---|
| Annual Deductible | Individual Family | $50 $150 | $75 $225 |
| Maximums | Individual Annual Maximum Individual Lifetime Orthodontic | $1,500 $1,500 | $750 N/A |
| Diagnostic and Preventive Services | Routine exams, X-rays, fluoride, and cleanings | No charge | No charge |
| Dental Cleanings | 4 cleanings per year | No charge | No charge |
| Basic Restorative Services | Fillings, extractions, emergency treatment | 80% Coinsurance* | 60% Coinsurance* |
| Major Restorative Services | Crowns, inlays and onlays, dentures, and bridges | 50% Coinsurance* | 40% Coinsurance* |
| Orthodontics | Orthodontia for you, your spouse, and your children up to age 26 | 50% Coinsurance* | N/A |
| *Deductible applies for lifetime maximums. | |||