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 $15.00
Type II - Basic Services	Patient Pays
One surface silver filling Two surface white filling, anterior Single tooth extraction Surgical removal of erupted tooth	$20.00 $45.00 $25.00 $45.00
Type III - Major Services	Patient Pays
Porcelain crown     (predominantly base metal) Molar root canal therapy Complete upper dentures Periodontal Scaling & root planing     (per quad)	$310.00 $300.00 $325.00 + Lab   $55.00
Type IV - Orthodontics	Patient Pays
Comprehensive orthodontic treatment for children to age 19
Evaluation	$35.00
Treatment Planning/Records	$250.00
Orthodontic Treatment	$1,800.00
Adults 19 years of age or older
Evaluation	$35.00
Treatment Planning/Records	$250.00
Orthodontic Treatment	$2,000.00
Retention	$450.00

This schedule shows only a few of the covered procedures. 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.