| 16 | Dental Insurance, continued BASIC PLAN PREMIER PLAN Delta PPO*** Delta Premier/ Out of Network Delta PPO*** Delta Premier/ Out of Network Deductible $25 $50 $15 $25 Individual Annual Maximum* $750 $750 $1,500 $1,500 Diagnostic & Preventive Exams, cleanings, space maintainers, Sealants, X-rays, Fluoride (Dependent Children Under 19) 100% covered 100% covered Routine Restorative Services Simple extractions, surgical services 10% after deductible 20% after deductible 10% after deductible 20% after deductible Emergency Treatment Routine Oral Surgery Posterior Composites 50% after deductible 50% after deductible Major Services Endodontics – root canal therapy Not covered 20% after deductible Periodontics – conservative and maintenance therapies Periodontics – complex procedures 50% after deductible Crowns, inlays, onlays Bridges and dentures Repairs and adjustments Orthodontics (Dependent Children Under 19) Appliances, treatment & related services Not covered 50% after deductible Lifetime Maximum** per dependent child $2,000 Dental Premium Cost – Per Pay Period Employee Only $5.89 $9.54 Employee + Child(ren) $13.20 $21.63 Employee + Spouse/DP $11.58 $19.05 Family $17.50 $28.85 *The Individual Annual Maximum is the maximum benefit each covered person is eligible to receive for certain covered services in 2024. **The Lifetime Maximum is the maximum benefit each covered person is eligible to receive for orthodontics in a lifetime. *** You will commonly pay less when seeing a Participating Delta Dental Dentist. For more information, please see the Dental SPD located on the HR Landing Page.