Principal Mutual Summary of Dental Benefits for EOC

Covered Benefit	In-Network covers	Out-of-Network covers
Preventive Services -cleanings, exams, x-rays, sealants, fluoride treatments	100% (Deductible waived)	100% (R & C) (Deductible waived)
Basic Services -restorative/fillings, endodontics, oral surgery	100%	80% (R & C)
Major Services -crowns, dentures, bridges, periodontic surgery	60%	50% (R & C)
Orthodontia -Seperate $50 deductible per individual -$1000 lifetime max per individual	50%	50% (R & C)
Deductible -3 deductibles per family maxium -per yea, Basic and Major combined -waived for preventive services	$50	$50
Plan Calendar Year Maximum Benefit	$1,500