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|  |   Select 25 OverviewThe 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 | $5.00 | Initial Exam | No charge | X-Rays (Bitewings) | No charge | Semi-Annual Cleaning | No charge | Sealant - per tooth | $10.00 | | | Type II � Basic Services | Patient Pays | One surface silver filling | $12.00 | Two surface white filling, anterior | 40.00 | Single tooth extraction | 15.00 | Surgical removal of erupted tooth | 40.00 | | | Type III � Major Services | Patient Pays* | Porcelain crown (high noble) | $275.00 | Porcelain bridge | $275.00 | One surface inlay | $85.00 | Molar root canal therapy | $250.00 | Complete upper dentures | $280.00 | | | Type IV � Orthodontics | Patient Pays* | Treatment for children/adults | 25% discount off usual fees | * Some services require additional lab fees. Calendar Year Deductible | None | Annual Maximum Benefit | None | Pre-Existing Condition Exclusion | No pre-existing condition exclusion applies | Exclusions and Limitations | 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. |