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DHMO Overview
CS150 Plan
The DHMO plan provides a wide variety of benefits through your participating provider. At the time of services, you pay the dentist for any applicable co-payments according to you schedule of benefits. The plan features:
  • No claims to file
  • No hidden costs
  • No Maximums
  • No waiting periods

Rates 
Effective date: 1/1/07

Bi-weekly Payroll Deductions
Employee..........................................$18.00
Employee and 1 Dependent.............$23.00
Employee and Family.......................$28.00

Monthly Bank Draft Deductions
Employee...........................................$39.00
Employee and 1 Dependent..............$49.83
Employee and Family........................$60.66

1 year rate
Type I - Preventive Services Patient Pays*
Office Visit *$5.00
Initial Exam *No Charge
X-Rays (Bitewings) *No Charge
Semi-annual Cleaning *No Charge
Sealant - Per Tooth *$10.00

Type II - Basic Services

Patient Pays*
One Surface silver filling *No Charge
Two Surface white filling, anterior *$40.00
One surface inlay, metallic *$95.00
Molar root canal therapy *250.00
Type III - Major Services Patient Pays*

Porcelain crown (high noble)

*$280.00 + Lab Fees
Porcelain Veneer *$280.00
Surgical removal of erupted tooth *$40.00
Complete upper dentures *$300.00

Type IV - Orthodontics

Patient Pays*

Treatment for children

Treatment for Adults
Consultation                                         *No Charge Consultation *No Charge
Evaluation *$35.00 Evaluation *$35.00
Records/Treatment Planning *$250.00 Records/Treatment Planning *$250.00
Orthodontic Treatment *$1800.00 Orthodontic Treatment *$2000.00
Retention *$450.00
Calendar Year Deductible None
Annual Maximum Benefit No Limit
Pre-Existing Condition Exclusion No pre-existing condition exclusion applies
Exclusions and Limitations Certain exclusions and limitations apply
This schedule shows only a few of the covered procedures. Please see your Benefit Administrator for a complete schedule. This schedule is intended for comparison purposes only. The benefits for each plan will be determined by the contract. For a complete listing of benefits and exclusions and limitations, please reference your certificate of coverage.

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