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CI e r <br />Deductible <br />Single <br />Family <br />Dependent Age Limit <br />Waived for Preventive <br />Preventive Services <br />Basic Services <br />Major Services <br />Annual Maximum <br />Orthodontia <br />Lifetime Maximum <br />Benefit Detail <br />Endodontic <br />Periodontal <br />Oral Surgery <br />Out of Network <br />Reimbursement <br />Rate Guarantee <br />Employee 19 <br />EE/Spouse 17 <br />EE/Child(ren) 3 <br />Family 31 <br />TOTAL 70 <br />Monthly Premium <br />Annual Premium <br />$ +/- Current <br />%+/- Current <br />.- <br />In -Network <br />Non <br />-Network <br />Delta Dental <br />In -Network Non -Network <br />$25 <br />$25 <br />$75 <br />$75 <br />Age 26 <br />Age 26 <br />Yes <br />Yes <br />100% <br />100% <br />100% 100% <br />100% <br />80% <br />100% 80% <br />60% <br />50% <br />60% 50% <br />$1,750 <br />$1,750 <br />50% <br />50% <br />$1,000 <br />$1,000 <br />Basic <br />Basic <br />Basic <br />Basic <br />Basic <br />Basic <br />Maximum <br />Allowable <br />Charge <br />Maximum Allowable Charge <br />12 Months <br />12 Months <br />Current <br />$30.99 <br />Renewal <br />$31.82 <br />Revised Renewal <br />$30.99 <br />$62.70 <br />$64.39 <br />$62.70 <br />$73.58 <br />$75.56 <br />$73.58 <br />$114.85 <br />$117.94 <br />$114.85 <br />$5,436 <br />$5,582 <br />$5,436 <br />$65,230 <br />$66,984 <br />$65,230 <br />$0 <br />$1,755 <br />62.7% <br />0.0% <br />This illustration is intended to outline the basic plan and is not intended to describe the contract provision. Each employee will receive a <br />plan booklet which will outline in detail the plan provisions and limitations. Should there be a discrepancy between this outline and the <br />plan document the plan document prevails. <br />