United Healthcare DMO Dental
BENEFITS* Standard DMO DentalWhat You Pay
Plan Maximums
Calendar Year Deductible
None
Calendar Year Maximum Benefit
None
Preventive Procedures
Office Visit
$0
$0
D1110- Cleaning Adult/Child
$0
D0210 − X -rays & I
Restorative Procedures
$65
D2391 White Filling (posterior)
D3330 Molar Endodontics (root canal)
$245
$180 -$375
D4261 Periodontal Osseous Surgery (gum disease)
$43-$55
D4342 Periodontal Scaling & Root Planing (gum disease)
Major Procedures
D5110 − D5120 Complete Denture (maxillary or mandibular)
$325
$400
D5211 − D5212 Partial Denture (maxillary or mandibular)
$45
D6240 Pontic (porcelain fused to a high noble metal)
$245
D6750 Crown (porcelain fused to a high noble metal)
$50
D7220 Surgery to remove impacted tooth (soft tissue)
Orthodontia
$2,250
D8080 Comprehensive Orthodontic Treatment (child)
$2,350
D8090 Comprehensive Orthodontic Treatment (adult)
* Please view the carrier’s schedule of benefits for a more comprehensive outline.
Sign up as a member online to print ID cards, locate providers, and view benefits and claims.
* Please refer to carrier booklet. Plan limits may apply. 21
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