| DHO 7 (October - September) |
| Plan Annual Maximum Benefit: |
$1,000 |
| Diagnostic & Preventive |
In Network |
Out of Network* |
| Exams — periodic, limited, comprehensive |
Covered at 100% |
Covered at 100% |
| Radiographs — full mouth series, panoramic, bitewings |
Covered at 100% |
Covered at 100% |
| Fluoride |
Covered at 100% |
Covered at 100% |
| Routine teeth cleaning |
Covered at 100% |
Covered at 100% |
| Sealants |
Covered at 100% |
Covered at 100% |
| Restorative & Prosthodontics |
|
|
| Fillings - silver or white (anterior and posterior teeth) |
Covered at 80% |
Covered at 80% |
| Protective restorations |
Covered at 80% |
Covered at 80% |
| Core build ups |
Covered at 50% |
Covered at 50% |
| Crowns — porcelain, ceramic, stainless steel |
Covered at 50% |
Covered at 50% |
| Removable dentures |
Covered at 50% |
Covered at 50% |
| Endodontics & Periodontics |
|
|
| Root canal therapy — anterior, posterior |
Covered at 80% |
Covered at 80% |
| Scaling and root planing |
Covered at 80% |
Covered at 80% |
| Full mouth debridement |
Covered at 80% |
Covered at 80% |
| Periodontal maintenance |
Covered at 80% |
Covered at 80% |
| Oral Surgery |
|
|
| Frenectomy |
Covered at 80% |
Covered at 80% |
| Simple extractions |
Covered at 80% |
Covered at 80% |
| Impactions |
Covered at 80% |
Covered at 80% |
| Surgical extractions |
Covered at 80% |
Covered at 80% |
| Miscellaneous |
|
|
| Emergency palliative treatment |
Covered at 100% |
Covered at 100% |
| Anesthesia — general and IV sedation |
Covered at 80% |
Covered at 80% |
