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High Option PPO
Under the High Option PPO plan, you and your family may choose any dentist (network and non-network). The High Option PPO plan has an individual calendar year deductible of $50 and a family deductible of $150. The maximum benefit for the High Option PPO plan is $1,500 per person per calendar year for all covered services. Preventive and diagnostic care is covered at 100 percent (no deductible) of reasonable and customary charges. After the deductible has been met, basic restorative treatment is covered at 80 percent of the PDP (Preferred Dentist Program) fee for in-network services; 80 percent of reasonable and customary charges for out-of-network services. Major restorative treatment is covered at 50 percent of PDP charges (in-network) or 50 percent of reasonable and customary charges (out-of-network). Orthodontic services are covered under this plan for children only at 50 percent with a $1,500 lifetime maximum.

Cost Calculator
Type:
My Dentist:
R&C:
PDP:
Deductable:
 
  In-Network
(100% PDP)		 Out-of-Network
(100% R&C)
Fee: $90.00 $97.00
Plan Pays: $90.00 $93.00
Out-of-Pocket: $0.00 $4.00
 
Savings: $4.00  
Tooth Numbering Chart
Tooth Numbering System Tooth
3rd molar (wisdom teeth)
2nd molar
1st molar
2nd bicuspid
1st bicuspid
cuspid
lateral incisor
central incisor		 Tooth Notation
1, 16, 17, 32
2, 15, 18, 31
3, 14, 19, 30
4, 13, 20, 29
5, 12, 21, 28
6, 11, 22, 27
7, 10, 23, 26
8, 9, 24, 25