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Delta Dental Delta PPO DHMO Services In-Network Out-of-Network In-Network Network Delta Dental PPO / DHMO Individual - $50 Individual - $50 Deductible Fee Schedule (E) Family - (E) Family - $150 (E) $150 (E) Plan Preventative 100% 100% Fee Schedule 01/01/2023 – 12/31/2023 Basic 80% after Deductible 80% after Deductible Fee Schedule Major 50% after Deductible 50% after Deductible Fee Schedule Provider Search Annual Maximum www.deltadental.com Annual Maximum $1,500 $1,500 Unlimited Orthodonture Additional Information Orthodonture 50% 50% Fee Schedule Children

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