Plan Information

Delta Dental PPO Dentists

This is a PPO plan. Delta Dental PPO participating dentists have agreed to file the claim for you and to accept the amount approved by Delta. Benefits for all dentists are based on Delta Dental’s reduced PPO fee schedule. PPO dentists will file the claim with Delta Dental. There is no balance billing for PPO dentists.

Delta Dental Fee Schedule
  Plan Pays
Year 1 Year 2 Year 3
Diagnostic & Preventive Procedures* Diagnostic: Routine periodic examinations twice in a calendar year.

Preventive: Dental prophylaxis (teeth cleaning) twice in a calendar year.

Radiography: Bitewing and full mouth x-rays.
80% 90% 100%
Basic Procedures*
(6 month waiting period)
Restorative: Amalgam fillings.

Other: Space Maintainers, recementation of crowns.
60% 70% 80%
Major Procedures*
(12 month waiting period)
Endodontics: Pulpal therapy and root canals.

Periodontics: Treatment of diseases of the gums.

Oral Surgery: Extractions and other oral surgery, including pre and post operative care.

Prosthetics: Gold restorations, crowns, bridges, partials and complete dentures.

Other: Pontics, repair of crowns and bridges, repair of full and partial dentures.
0% 40% 50%
* Combined Deductible for Diagnostic, Basic and Major Procedures: $50 per person per calendar year.

Annual Plan Maximum - $1500

Orthodontia Procedures**
(12 month waiting period)
($350 calendar year maximum)

($1000 lifetime maximum per person for this benefit)

Orthodontic benefits are only available for eligible dependent children.
0% 40% 50%
** Orthodontia Deductible: $100 lifetime.