EXAMPLE 1: Preventive Services
Periodic Oral exam / 2 intraoral x-rays & adult prophylaxis(cleaning)
|
Delta Dental PPO™ |
Delta Dental Premier |
Non-Network Dentist |
Sample Dentist Charge |
$195 |
$195 |
$195 |
|
Sample Allowed Charged
|
$127 |
$170 |
$127 |
|
Benefit Percentage
|
100% |
100% |
100% |
|
Your Dental Benefit
|
$126.75 |
$171.60 |
$126.75 |
|
Member Pays
|
$0.00 |
$0.00 |
$68.25 |
|
Network Savings
|
$68 |
$23 |
$0 |
|
EXAMPLE 2*: Restorative Services
Amalgam one surface, resin composite one surface, extraction erupted tooth
|
Delta Dental PPO™ |
Delta Dental Premier |
Non-Network Dentist |
|---|
|
Sample Dentist Charge
|
$495 |
$495 |
$495 |
Sample Allowed Charged |
$322 |
$436 |
$322 |
Benefit Percentage |
80% |
80% |
80% |
Your Dental Benefit |
$257.40 |
$348.48 |
$257.40 |
Member Pays |
$64.35 |
$87.12 |
$237.60 |
Network Savings |
$173 |
$59 |
$0 |
Please Note: The example above assumes the deductible has been satisfied.
|
EXAMPLE 3*: Major Restorative Services
Root Canal - Molar & porcelain crown
| Delta Dental PPO™ |
Delta Dental Premier |
Non-Network Dentist |
|---|
Sample Dentist Charge |
$1,800 |
$1,800 |
$1,800 |
Sample Allowed Charged |
$1,440 |
$1,620 |
$1,440 |
Benefit Percentage |
50% |
50% |
50% |
Your Dental Benefit |
$720.00 |
$810.00 |
$720.00 |
Member Pays |
$720.00 |
$810.00 |
$1080.00 |
Network Savings |
$360 |
$180 |
$0 |
Please Note: The example above assumes the deductible has been satisfied.
|
Total Results of Examples
|
Delta Dental PPO™ |
Delta Dental Premier |
Non-Network Dentist |
|---|
Benefit Total |
$1,104.15 |
$1,330.08 |
$1,104.15 |
Member Amount Paid |
$784.35 |
$897.12 |
$1,385.85 |
Annual Maximum |
$1,500.00 |
$1,500.00 |
$1,500.00 |
Benefits Remaining |
$395.85 |
$169.92 |
$395.85 |