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Dental Insurance <br />Delta Dental <br />Monthly Rates <br />Delta Dental <br />Type of Service <br />Annual Deductible (Individual/Family) <br />Employee <br />Share <br />TIER 1 <br />City <br />Share <br />Total <br />Premium <br />Employee <br />Share <br />TIER 2 <br />City <br />Share <br />Total <br />Premium <br />Employee <br />$5.58 <br />$31.61 <br />$37.19 <br />$9.53 <br />$27.66 <br />$37.19 <br />Employee & Spouse <br />$15.05 <br />$60.22 <br />$75.27 <br />$22.58 <br />$52.69 <br />$75.27 <br />Employee & Child(ren) <br />$20.79 <br />$83.17 <br />$103.96 <br />$31.19 <br />$72.77 <br />$103.96 <br />Family <br />$28.41 <br />$113.63 <br />$142.04 <br />$42.61 <br />$99.43 <br />$142.04 <br />Delta Dental <br />Type of Service <br />Annual Deductible (Individual/Family) <br />Benefits Summa <br />Dental PPO + Premier Network <br />$50 / $150 <br />Calendar Year Maximum (Individual) <br />$2,000 <br />Diagnostic & Preventive Benefits <br />Diagnostic & Preventive Services <br />NO <br />Plan pays 100% <br />Dental X -Rays <br />Plan pays 100% <br />Sealants <br />PREMIUM Plan pays 100% <br />Basic Benefits <br />OR PLAN <br />Oral Surgery Services <br />DESIGN Plan pays 80% <br />Endodontic Services <br />CHANGES Plan pays 80% <br />Periodontic Services <br />Plan pays 80% <br />Basic Restorative Services <br />Plan pays 80% <br />Major Benefits <br />Implant Coverage <br />Plan pays 50% <br />Relines and Repairs <br />Plan pays 50% <br />Special Restorative Services <br />Plan pays 50% <br />Prosthodontic Services <br />Plan pays 50% <br />TMD/TMJ Treatment <br />Plan pays 50% ($1,000 Lifetime Maximum) <br />Orthodontic Benefits <br />$1,500 Lifetime Maximum <br />Orthodontic Services <br />Plan pays 50%, up to maximum, until age 19 <br />* Important: Non -Participating Dentists are allowed to balance bill. Employees and/or Dependents are responsible for the difference between the non- <br />participating Maximum Plan Allowance and the full fee charged by the Dentist. <br />7 <br />