AREA

EMPLOYEE ONLY

EMPLOYEE + SPOUSE

EMPLOYEE + CHILD

EMPLOYEE
+2 or 3 DEPENDENTS

EMPLOYEE +4 OR MORE DEPENDENTS

1

$91.08

$179.70

$147.54

$253.44

$305.52

2

$99.24

$194.58

$160.80

$276.24

$333.06

3

$108.24

$212.10

$175.32

$301.20

$363.12

4

$117.96

$231.24

$191.10

$328.32

$395.82

5

$128.64

$252.12

$208.38

$357.96

$431.58

6

$140.22

$274.74

$227.10

$390.24

$470.46