CS150 Overview


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CS150 DHMO Overview

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 (high noble) Porcelain bridge One surface inlay Molar root canal therapy Complete upper dentures	$280.00 $280.00 $95.00 $250.00 $300.00

Type IV – Orthodontics	Patient Pays*

Treatment for children to age 19 Evaluation Treatment Planning Orthodontic Treatment	$35.00 $250.00 $1800.00

* Some services require additional lab fees.

Calendar Year Deductible	None
Annual Maximum Benefit	None
Pre-Existing Condition Exclusion Exclusions and Limitations	No pre-existing condition exclusion applies Certain exclusions and limitations apply

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.

To submit comments or questions, please visit our Contact Center.