This table is a summary only . The plan is available for California only
| Type of service | Copayments |
| Diagnostic service | No cost - $ 5 |
| Preventive Services | No cost - $ 150 |
| Restorative Services | No cost - $ 425 |
| Endotontic Serives | $ 25 - $ 725 |
| Periodontic Services | $ 50 - $ 650 |
| Prosthondic Services | $ 50 - $ 600 |
| Oral and Maxillogical Surgery | $ 35 - $ 230 |
| Orthodontic Services | $ No cost $ 2700 |
| Adjunctive General Services | No cost - $ 70 |
| Outpatient services | No coverage |