The HMO Dental plan provides dental benefits with attractive prepayment fees. To receive the benefits of the HMO Dental Plan you will need to select a Plan Dentist for you and your family members from the list of Plan Dentists. Please note that you may choose a different dentist for each family member.
Features of the HMO Dental Plan:
- No deductible
- No claim forms
- No annual maximum
- Fixed copayment schedule for Plan dentists
- Reduced fees on Orthodontic procedures for children and adults
- No referral required for Specialty Dentists benefits
- Benefits for pre-existing dental conditions
| |
Your Cost |
| Detal Treatment |
With DMO |
Average Price |
| Appointment |
|
|
Periodic Oral Evaluation
Limited Oral Exam
Comprehensive Oral Evaluation |
No Charge
$25
No Charge |
$30
$47
$50 |
| Diagnostic Dentistry |
|
|
| Complete X-Ray Series including Bitewings |
$5 |
$83 |
| Preventive Dentistry |
|
|
Routine Cleaning - Adut (once every 6 mos.)
Routine Cleaning - Child (once every 6 mos.)
Application of Fluoride (up to 18 years of age)
Oral Hygene Instruction
Application of Sealant per Tooth
Fixed Space Maintaine |
$5
$5
No Charge
No Charge
$15
$70** |
$61
$44
$20
$25
$37
$354 |
| Fillings / Crowns |
|
|
Silver Fillings
- One Surface
- Two Surfaces
- Three Surfaces |
$15
$20
$30 |
$79
$100
$121 |
White Fillings
- One Surface, Anterior
- Two Surfaces, Anterior
- Three Surfaces, Anterior
- One Surface, Posterior
- Two Surfaces, Posterior
- Three Surfaces, Posterior |
$40
$50
$70
$80
$90
$100
$300** |
$99
$127
$160
$113
$148
$182
$779 |
Crowns-Porcelain to High Noble Metal
(cost of precious & semi-precious metal is additional) |
$300 |
$799 |
| Core Build up |
$85 |
$162 |
| Root Canals |
|
|
Anterior
Bicuspid
Molar |
$100
$190
$200 |
$485
$573
$712 |
| Periodontics |
|
|
Periodontal Scaling and Root Planing Per Quadrant
Full Mouth Debridement (Complicated Cleaning) |
$55
$63 |
$162
$105 |
| Dentures |
|
|
Complete Denture - Upper
Complete Denture - Lower
Partial Denture - Upper
Partial Denture - Lower |
$335**
$335**
$390**
$390** |
$864
$794
$794
$508 |
| Oral Surgery |
|
|
| Single Tooth Extraction |
$20 |
$88 |
Removal of Impacted Tooth
- Soft Tissue
- Partial Bony Partial Bony
- Complete Bony
- Complete Bony, with Complications |
$75
$100
$140
$170 |
$218
$274
$326
$388 |
| ** Members are responsible for additional lab fees for these services. |
| * The Average Retail Charges were determined by "Company" claims analysis for the year. |
| 2003. The Retail Charges represent a mean average rounded to the nearest dollar representing what you may pay without the plan services. |
| *** EZ Dental Plan is marketed by Assurance Employee Benefits and only available in AL, AZ, CA, FL, GA, IL, KS, KY, MO, NJ, NM, NY, OH, OK, PA, TN, and TX. |
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