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| House Blended - Delta Dental DHMO Plan |
| Plan Design & Benefits |
House Blended - Delta Dental DHMO Plan |
In-Network |
Out Of Network |
| Annual Benefit Maximum |
None |
No Out Of Network Benefits Available |
| Annual Deductible Individual |
None |
| Annual Deductible Family |
None |
| Waiting Periods |
None |
| Preventive Services |
| Office Visit |
100% |
| Exam |
100% |
| X-Rays |
100% |
| Cleaning (Prophylaxis) |
100% |
| Basic Services |
| Fillings (Restorative) |
No Charge |
| General Anesthesia |
$0 - $250 |
| Oral Surgery |
$0 - $15 |
| Periodontal Services |
$10 - $20 |
| Endodontic Services |
$40 - $95 |
| Major Services |
| Crown |
$110 - $130 |
| Bridges/ Dentures |
$110 - $130 |
| Prosthetics |
$10 - $150 |
| Orthodontia |
| Retention, Active Treatment |
up to $2,000 |
| Dental Plan Payroll Contributions |
| Tier Of Coverage |
House Blended Per Pay Period Contribution |
| Team Member (“TM”) Only |
$6.35 |
| TM + Child(ren) |
$11.77 |
| TM + Spouse/Domestic Partner |
$11.86 |
| Family |
$17.08 |
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