DELTA DENTAL PLAN Services Delta DHMO Network In-Network ▪ Delta Dental TOA Deductible Individual: $50 Family: $150 Plan Preventative Services ▪ 1/1/2021 –12/31/2021 Cleanings X-Rays Subject to Fee Schedule Provider Search Oral Exams Space Maintainers www.deltadental.com Sealants Basic Services Additional Information Fillings Subject to Fee Schedule ▪ Table of Allowance Simple Tooth Extractions Schedule Major Services Periodontics / Endodontics Oral Surgery Subject to Fee Schedule Crowns / Inlays / Onlays / TMJ Prosthodontics – Bridges, Dentures and Implants Annual Maximum $1,000 17 17