Which plan is right for you?
Below you can compare features and your cost for certain procedures for each DHMO dental option – Select Standard and Select High. For more details, you can view a Complete List of program details for each option at the bottom of the charts.
| Select Standard | Select High | |||||
| Features | ||||||
| Office Visit Copay | $10 | $10 | ||||
| Deductibles | None | None | ||||
| Annual Maximum Limits | None | None | ||||
| Lifetime Maximum Limits for Orthodontics | None | None | ||||
| Waiting Periods | None | None | ||||
| Claims Forms | None | None | ||||
| Must Use a Network Dentist | Yes | Yes | ||||
| Examples | Average Cost Without a Plan1 | You Pay | You Pay | |||
| I. Basic | ||||||
| Oral Examination | $85 | $0 | $0 | |||
| Bitewing X-Rays (1-4 Films) | $33 | $0 | $0 | |||
| Cleaning for Adults (2 per year) | $101 | $0 | $0 | |||
| Sealant (per tooth) | $57 | $0 | $0 | |||
| Fluoride Varnish | $40 | $0 | $0 | |||
| II. Intermediate | ||||||
| Complete Series X-Rays | $160 | $0 | $0 | |||
| Silver Filling (Three Surfaces) | $217 | $76 | $0 | |||
| Composite Filling (Two Surfaces) | $217 | $68 | $20 | |||
| Extraction (Erupted Tooth) | $170 | $58 | $47 | |||
| III. Major | ||||||
| Periodontal Scaling/Root Planing | $247 | $105 | $31 | |||
| Perio Surgery (Gingivectomy/Gingivoplasty) | $678 | $351 | $205 | |||
| Root Canal (Molar) | $1,074 | $587 | $416 | |||
| Crown (Porcelain Fused to Base Metal) | $1,298 | $555 | $380 | |||
| Denture (Complete Upper/Lower) | $1,784 | $702 | $455 | |||
| Implant (Endosteal, surgical placement) | $2,503 | $1,292 | $830 | |||
| IV. Orthodontia | ||||||
| Children | $6,552 | $3,422 | $3,422 | |||
| Adults | $7,025 | $3,658 | $3,658 | |||
| Complete List of Program Details | Select Standard | Select High | ||||
1 Approximate percentage of coverage based on the Captiva context fee schedule’s 80th percentile. A specific fee schedule applies and will be mailed with your Membership Card. Please see the Complete List of Benefits for a list of member fees.
