Plan Details
Plan Name	Delta Dental DHMO
Effective Dates	Jan 01, 2025 to Jan 01, 2026
Benefits	In-Network	Out-of-Network
Annual Deductible/Individual	$0	N/A
Annual Deductible/Family	$0	N/A
Annual Plan Maximum	N/A	N/A
Lifetime Orthodontia Plan Maximum	N/A	N/A
Diagnostic and Preventive Services	copays vary between $0 and $165 depending on service	N/A
Major Services	copays vary between $0 and $240 depending on service	N/A
Basic Services	copays vary between $0 and $280 depending on service	N/A
Orthodontia Services	copays vary between $25 and $1900 depending on service	N/A
Ortho Dependent Children	$1,700	N/A
Ortho Adults	$1,900	N/A