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LM <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 18 <br />EE/Child(ren) 3 <br />Family U <br />TOTAL 72 <br />Monthly Premium <br />Annual Premium <br />S +/- Current <br />%+/- Current <br />Mayfield Village <br />Dental Benefit & Cost Comparison <br />Effective Date: 4/1/2021 <br />This illustration is intended to outline the basic plan and is not intended to describe the contract provision. <br />Each employee will receive a plan booklet which will outline in detail the plan provisions and limitations. <br />Should there be a discrepancy between this outline and the plan document the plan document prevails. <br />EXHIBIT A <br />