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Dental Procedure Costs - Preferred Provider Option (PPO) Plans

The following chart provides a comparison of costs for certain procedures covered by the state-sponsored dental plans. Please consult each dental plan's Evidence of Coverage for detailed information and plan limitations.

Comparison of Dental Plan Benefits
Type of Plan Delta Dental PPO plus Premier Basic Delta Dental PPO plus Premier Basic Delta Dental PPO plus Premier Enhanced PPO/using Participating Provider PPO/using Non-Participating Provider
Who is Covered Represented Employees Dependents of Represented Employees Excluded Employees and Dependents Employees and Dependents Employees and Dependents
Diagnostic and Preventive Benefits (two cleanings annually) No charge* No charge* No charge* No charge** 20%
Basic Benefits 10% 20% 10% 10%* 20%
Crowns 20% 50% 20% 20%* 50%
Bridges, Full & Partial Dentures 50% 50% 50% 40% 50%
Implant Benefit N/A N/A N/A Will pay 50% up to a lifetime maximum of $2,500 Will pay 50% up to a lifetime maximum of $2,500
Orthodontia Will pay up to 50% of approved fee for orthodontia, with a lifetime maximum for this benefit of $1,000 for adult Will pay up to 50% of approved fee for orthodontia, with a lifetime maximum for this benefit of $1,000 for dependent Will pay up to 50% of approved fee for orthodontia, with a lifetime maximum for this benefit of $1,000 for adults and dependent children Will pay up to 50% of approved fee, with a lifetime maximum of $1,000 for each adult and $1,500 for dependent children Will pay up to 50% of approved fee, with a lifetime maximum of $1,000 for each adult and dependent children
Annual Deductible $50* $50* $25* $25* $75
Maximum Deductible $150 per family $150 per family $100 per family $100 per family $200 per family
Annual Maximum $2,000 $1,000 $2,000 $2,000 $1,000

*Diagnostic and Preventive Benefits are exempt from the deductible.

**The level of benefits and covered services reflected in the chart are based on services provided by a PPO Plan dentist; for services provided by a non-PPO plan dentist, the level of benefits is lower. Additionally, the PPO includes a 3rd cleaning for high-risk patients and a benefit for dental implants (up to $2,500 lifetime maximum).

  Updated: 9/29/2015
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