Sample Claims:

EXAMPLE 1: Preventive Services

Periodic Oral exam / 2 bitewing x-rays & adult prophylaxis(cleaning)

 Delta Dental PPO™ Delta Dental Premier® Non-Network Dentist

Sample Dentist Charge 

$200

$200

$200

Sample Allowed Charged 

$130

$165

$180

Benefit Percentage 

100%

100%

100%

Your Dental Benefit 

$130

$165

$180

Member Pays 

$0

$0

$20

Network Savings 

$70

$35

$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 

$500

$500

$500

Sample Allowed Charged 

$325

$425

$460

Benefit Percentage 

80%

80%

80%

Your Dental Benefit 

$260

$340

$368

Member Pays 

$65

$85

$132

Network Savings 

$175

$75

$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 

$1,300

$1,600

$1,750

Benefit Percentage 

80%

80%

80%

Your Dental Benefit 

$1,040

$1,280

$1,400

Member Pays 

$260

$320

$400

Network Savings 

$500

$200

$0

*Please Note: The example above assumes the deductible has been satisfied.