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 Fee2 Your Fee
Oral Exam $73 $0 $0
Complete Series X-rays $190 $0 $0
Bitewing X-Rays (2 Films) $62 $0 $0
Semiannual (2) Teeth Cleanings $122 $0 $0
Topical Flouride for Children $60 $0 $0
Sealants $76 $0 $0
Filling (3-Surface/Silver) $345 $76 $0
Crown (Porcelain/Metal) $1,499 $555 $380
Implants $2,839 $1,292 $830
Complete Denture $2,218 $702 $455
Root Canal (Anterior Tooth) $1,157 $391 $260
Perio Scaling/Root Planing $346 $105 $31
Extraction, Erupted Tooth $235 $58 $47
Child Orthodontics $6,120 $3,422 $3,422
Adult Orthodontics $6,330 $3,658 $3,658
Complete List of Program Details Select

Standard

Select

High

1 Based on the Context4Healthcare’s 80th percentile for zip 220. Coverage for orthodontia is based on Dominion National’s 80th percentile of in-network and out-of-network claims data for D8080 and D8090 from 2016 to 2019.
2 There is an additional $10 for the office visit fee (per visit, not per procedure).