This example shows your estimated cost for a cleaning* if you have Blue Dental PPO Standard. With this plan, we cover 80 percent of the cost of a cleaning in network, 50 percent out of network. Other plans may cover different amounts. Remember, PPO and Blue Par Select dentists accept our approved amount. Out-of-network dentists don't. So you're responsible for paying the difference between the dentist's charge and the amount we approve.

Blue Dental PPO Standard estimated cost example

Payment Categories	PPO (in-network) dentist	Blue Par Select dentist	Out-of-network dentist
Dentist's fee	$76	$76	$100
Our approved amount for this service	$53	$76	$76
We pay	$42.40	$38	$38
You pay	$10.60	$38	$62

*The cost of the cleaning is based on prices in Southwest Michigan. Costs may vary around the state.