The DHMO plan provides a wide variety of benefits through your participating provider. At the time of services, you pay the dentist for any applicable copayments according to your schedule of benefits. The plan features:

• No claims to file
• No hidden costs
• No maximums
• No waiting periods
  
  
  

Type I - Preventive Services	Patient Pays
Office Visit Initial Exam X-Rays (Bitewings) Semi-Annual Cleaning Sealant - per tooth	$5.00 No Charge No Charge No Charge $10.00
Type II - Basic Services	Patient Pays
One surface silver filling Two surface white filling, anterior Single tooth extraction Surgical removal of erupted tooth	No Charge $40.00 No Charge $40.00
Type III - Major Services	Patient Pays
Porcelain crown     (predominantly base metal) Molar root canal therapy Complete upper dentures Periodontal scaling & root planing	$280.00 $250.00 $300.00 + lab   $50.00
Type IV - Orthodontics	Patient Pays
Comprehensive orthodontic treatment for children to age 19
Evaluation Treatment Planning/Records Orthodontic Treatment	$35.00 $250.00 $1800.00
Adults 19 years of age or older
Evaluation Treatment Planning/Records Orthodontic Treatment	$35.00 $250.00 $2000.00

This schedule shows only a few of the covered procedures. Please see your Benefit Administrator for a complete schedule. This schedule is intended for comparison purposes only. The benefits for each plan will be determined by the contract. For a complete listing of benefits and exclusions and limitations, please reference your certificate of coverage.