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 | Select |
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).