Dental Plan Comparison – Delta Dental   High Plan Standard Plan Plan Type PPO In Network Out of Network Plan Design: Individual Deductible $25 $50 $100 Family Deductible $150 Annual Max (Non-Ortho) $1,750 $1,250 $1,500 $1,000 Preventive Care 100% 100% U&C Applies Class II - Basic Restorative 80% subject to deductible 80% subject to deductible, subject to U&C 60% subject to deductible 60% subject to deductible, subject to U&C Class III - Major Restorative 50% subject to deductible 50% subject to deductible, subject to U&C Class IV - Ortho (including child and adults) 50% 50% subject to U&C Not Covered Ortho Life Time Max Not Applicable ©2014 Trinity Health - Livonia, MI