| Dental Services | Employee Cost | Plan Pays |
| Deductible | Individual: $75.00 | $0.00 |
| Preventative and Diagnotic | None | 100% Usual and Customary |
| Basic Restorative | 20% after deductible met | 80% Usual and Customary |
| Major | 50% after deductible met | 50% Usual and Customary |
| Orthodontia | 50% after deductible met | 50% up to lifetime maximum of $1,000 |
| Calendar Year Maximum | $1,000 |
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[Updated 12/23/2005]