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Martin County Sheriff's Office I Employee Benefit Highlights 12020-20210 <br /> Delta Dental Table of Allowance (TOA) Plan At-A-Glance <br /> Network Delta Dental PPO <br /> Calendar Year Deductible(CYD) In Network and Out of Network Combined <br /> i Per Member _-�i $50 - - Q Family $150 <br /> Waived for Diagnostic&Preventative Services? Yes <br /> i. Locate a Provider <br /> CalendarYear Benefit Maximum <br /> To search for a participating provider, <br /> Per Member $1,500 • contact Delta Dental's customer service <br /> or visit www.deltadentalins.com. <br /> Maximum Plan When completing the necessary <br /> Diagnostic&Preventive Services Code Allowance(MPA) search criteria,select Delta Dental PPO <br /> [Comprehensive Oral Exam D0120 Up to$45 network. <br /> Routine Cleanings—Adult/Child(2 Per Year) D1110/20 Up to$98/$70 . <br /> [Bitewing X-rays* ! . D0272 Up to$30 <br /> Panographic X-rays(1 Set Every 5 Years) - J D0330 Up to$75 <br /> Intraoral/Complete Series X-Rays D0210 Up to$94 <br /> •Full Mouth Depridement(Deep Cleaning) D4355 Up to$84 Plan References <br /> *Bitewing X-rays:One(1)set per <br /> Basic Services calendaryear for employee and spouse. <br /> r Two(2)sets per calendar year for <br /> LAmalgamFillings(3Surfaces;Permanent orPrimary) _1. D2160 Up to$120 <br /> dependent children enrolled. <br /> Resin-based Composite Filling(3 Surfaces,Anterior) ] D2332 Up to$144 <br /> Resin-based <br /> Composite Filling(3 Surfaces,•Posterior) ] D2393 Up to$120 <br /> Simple Extraction—Removal of Erupted Tooth or Root D7140 Up to$80 <br /> Surgical Extraction—Removal of Impacted Tooth - D7240 Up to$228 41111) <br /> Endodontics(Root(anal.Molar)—Excluding Final Restoration 03330 Up to$557 <br /> Important Notes <br /> Periodontal Maintenance Services(2 Per Year) D4910 Up to$83 <br /> •Each covered family member <br /> Major Services may receive up to two(2)routine <br /> [t cleanings per calendar year covered <br /> Deep Sedation/General Anesthesia(Each 15 Minute Increment) ] D9223 Up to$50 under the preventive benefit. <br /> Crown—Porcelain Fused to High Noble Metal 1 D2750 Up to$370 •A pretreatment estimate is <br /> Pontic=Porcelain Fused to High Noble Metal D6240 Up to$360 recommendedfor all work that <br /> is considered expensive.Member <br /> rComplete Denture—Maxillary D5110 Up to$485 must ask their dentist to submit the <br /> request to Delta Dental. <br /> Orthodontia •Waiting periods and age limitations <br /> I Lifetime Maximum 1 Up to$1,500 mayappty. <br /> Benefit i 50%Coinsurance of MPA •Benefit frequency limitations may <br /> apply to certain services. <br /> •for a full list of covered services <br /> and the MPA payable,please <br /> refer to the carrier's summary <br /> plan document. <br /> 119 <br /> ©2016,Gehring Group,Inc.,All Rights Reserved 10 <br />