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Delta Dental
Plan Type PPO
Plan Name PPO C 1500
Annual Deductible $25
Annual Maximum Benefit $1,500
Preventive ‐ X‐Rays, Teeth Cleaning) 100%
Oral Surgery / Restorative / Periodontics, Endodontics 80&
Crowns 60%
Orthodonitcs (child ‐ only) 50% to $1,000
Sample Rate
Emplyee $ 58.86
Employee + 1 Dependent $ 116.44
Employee + 2 plus Dependent $ 180.49
Your Cost / Emplyee $ ‐
Your Cost / Employee + 1 Dependent $ 57.58
Your Cost / Employee + 2 plus Dependent $ 121.63
*Premium is based on zipcode and age / Above sample is only a rough premium
