Which plan is right for you?
Below you can compare features and your cost for certain procedures for each Dental HMO 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 chart.
| Select Standard | Select High | ||
| Features | |||
| Office Visit Copay | $10 | $10 | |
| Deductibles | None | None | |
| Annual Maximum Limit | None | None | |
| Lifetime Maximum Limit for Orthodontics | None | None | |
| Waiting Periods | None | None | |
| Claims Forms | None | None | |
| Must Use a Network Dentist | Yes | Yes | |
| Comparison | Area Charge1 | Your Fee | Your Fee |
| Oral Exam | $71 | $0 | $0 |
| Complete Series X-rays | $189 | $0 | $0 |
| Bitewing X-Rays (2 Films) | $61 | $0 | $0 |
| Semiannual (2) Teeth Cleanings | $120 | $0 | $0 |
| Topical Flouride for Children | $49 | $0 | $0 |
| Sealants | $74 | $0 | $0 |
| Filling (3-Surface/Silver) | $338 | $76 | $0 |
| Crown (Porcelain/Metal) | $1,291 | $555 | $380 |
| Implants | $2,825 | $1,292 | $830 |
| Complete Denture | $2,164 | $702 | $455 |
| Root Canal (Anterior Tooth) | $1,134 | $391 | $260 |
| Perio Scaling/Root Planing | $342 | $105 | $31 |
| Extraction, Erupted Tooth | $232 | $58 | $47 |
| Child Orthodontics | $6,233 | $3,422 | $3,422 |
| Adult Orthodontics | $6,420 | $3,658 | $3,658 |
| Complete List of Program Details | Select Standard | Select High | |
1 Based on the Context4Healthcare’s 80th percentile. Coverage for orthodontia is based on the 80th percentile of Dominion Dental Services’ out-of-network claims data for D8080 and D8090 (excluding Invisalign) from 2015 to 2018. Based on zip 223.
