DENTAL BENEFITS Low Plan High Plan $50 per individual – Not to Deductible (Single / Family) $50 per individual – Not to Deductible (Single / Family) exceed $150 as a family exceed $150 as a family Annual Plan Maximum $1,250 / Individual Annual Plan Maximum $1,500 / Individual Preventive Services 100% Covered Preventive Services 100% Covered Exams, Cleanings, Fluoride, X-Rays Exams, Cleanings, Fluoride, X-Rays Basic Restorative 80% Covered Basic Restorative 80% Covered Fillings, Extractions, Endodontics, Crown Repairs Fillings, Extractions, Endodontics, Crown Repairs Major Restorative 50% Covered Major Restorative 50% Covered Crowns, Dentures, In/Outlays, Periodontics Crowns, Dentures, In/Outlays, Periodontics Orthodontia Services Not Orthodontia Services 50% Covered Children and Adults Covered Children up to age 19 Orthodontia Lifetime Maximum Not Covered Orthodontia Lifetime Maximum $1,500