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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
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800-228-3384
Delta Care USA DHMO
CAA 22
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800-422-4234
Member Pays
Met Life
SG 150
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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
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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