SAMPLE BENEFITS AND COPAYMENTS FOR PANEL (DHMO) DENTAL PLANS A Complete Description of Benefits is Attached to Application and Instructions Plan Provider Finder Customer Service Benefit Preventive/Diagnostic Services Office Visit Teeth Cleaning X-Rays (full mouth) Topical Fluoride Sealant (per tooth) Diagnostic Casts (non-orthodontic) Emergency Office Visit UHC DHMO Value 161 Click Here 800-228-3384 Delta Care USA DHMO CAA 22 Click Here 800-422-4234 Member Pays Met Life SG 150 Click Here 800-275-4638 $0 $0 (2 times per year) $0 $0 (under age 18) Not Covered $10 $10 $0 $0 (1 per 6 month period) $0 $0 (to age 19) $10 (under age 15) $0 $0 $5 per visit $0 (2 times per year) $0 $0 (adult or child) $8 $0 $0 $15 $20 $26 $7 $0 $0 $0 $15 $8 $12 $18 $0 $16 $50 $65 $90 $40 $3 $40 $60 $80 $8 $0 $50 $100 $125 $30 $10 $24 $22 $100 $130 $175 $0 $0 $0 $45 $90 $135 $0 $0 $0 $100 $110 $200 $115 $200 $125 $250 $75 $325 $30 $165 $245 $5 $90 $90 $35 $150 $150 $250 $225 $65 $125 $125 $45 $175 $150 $50 $1,695 $1,600 $1,695 $30.18 $55.90 $56.31 $32.35 $46.20 $63.53 $29.64 $48.62 $60.32 Click Here Apply Now Click Here Apply Now Click Here Apply Now Restorative Dentistry Amalgam Restoration-1 surface Amalgam Restoration-2 surfaces Amalgam Restoration-3 surfaces Sedative Filling Oral Surgery Extraction-single tooth-uncomplicated Extraction-impacted tooth-soft tissue Extraction-impacted tooth-partial bony Extraction-impacted tooth-bony Surgical removal of erupted tooth Endodontics Pulp Capping-direct Pulp Capping-indirect Therapeutic pulpotomy Root Canal-per tooth-anterior Root Canal-per tooth-bicuspid Root Canal-per tooth-molar Periodontics Gingivectomy-per quadrant Mucogingival Surgery-per quadrant Crowns Stainless Steel crown Porcelain crown –not for molars Porcelain crown- for molars Prosthetics Complete denture – upper or lower Partial denture-upper or lower Reline-lab processed Orthodontics Class I,II,III – benefit covers consultation, appliances, banding, and monthly office visits for 24 months Premiums(monthly) Member Member +1 Member + 2 or more Link to Complete Description of Benefits Link to Application and Instructions Panel (DHMO) Dentist Plan Matrix 12012013