Dental HMO Plan

Sample Co-Pays

• Detailed Oral exam = No cost• X-Rays = No cost

• Office Visit = $5.00 • Teeth Cleaning = $5.00 (One teeth cleaning every 6 months)

• Fillings = $8.00 (Amalgam one surface)• Tooth Extraction = $10.00

• Root canals = $165 to $365• Crowns = $185 to $395

• Complete Denture (Maxillary) = $365 • Braces = Child $1,150.00 / Adult $2,100.00

Full List of Description of Benefits and Co-Pays at www.______.awisdental.com

State by State AvailabilityState(s) Individual Family

CA,FL,PA,NJ,NY,MD $39.95 a month/$60 one-time App Fee $89.95 a month/$100 App Fee

Texas $39.95 a month/$60 one-time App Fee $89.95 a month/$60 App Fee

AZ,KY,NM*,OH,TN $49.95 a month/$60 one-time App Fee $89.95 a month/$100 App Fee

Georgia $59.95 a month/$60 one-time App Fee $109.95 a month/$60 App Fee

Nevada $59.95 a month/$60 one-time App Fee $119.95 a month/$100 App Fee

Washington State* $69.95 a month/$60 one-time App Fee $139.95 a month/$100 App Fee

Hawaii* $69.95 a month/$60 one-time App Fee $149.95 a month/$100 App Fee

Virginia* $79.95 a month/$60 one-time App Fee $169.95 a month/$100 App Fee

Health and life Insurance License required in MD, NV, UT, OR, and SD

NY and MD Dental HMO Plans on www.getfamilycaredental.com

All other States on www.awisdental.com

* These States will open on Feb 1st.