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  Baptist Health South Florida
  About CompBenefits
  Option I:
  CS-250 Basic DHMO Overview
  CS-250 Basic DHMO Schedule
  CS-250 Basic DHMO FAQ
  Search for Providers
  Search for Specialist

  Option II:

  CS-150 Premier DHMO Overview
  CS-150 Premier DHMO Schedule
  CS-150 Premier DHMO FAQ
  Search for Providers
  Search for Specialist

  Option III:

  Elite Preferred 510 Overview
   Elite Preferred 510 Schedule
   Elite Preferred 510 Claim Form
   Elite Preferred 510 FAQ

  

Search for Providers
   Search for Specialist
  Contact
 



CS-250 Basic DHMO Schedule

ADA
CODE
Procedure Member Pays
 
APPOINTMENTS
9310 Consultation
(diagnostic service provided by dentist other than practitioner providing treatment)
20.00
9430 Office visit (normal hours) 5.00
9440 Emergency visit (after regularly scheduled hours) 35.00
9999 Emergency visit during regularly scheduled hours, by report 20.00
9999 Broken appointments
(without 24 hr notice, per 30 min.)

Maximum $40 per broken appointment. No Charge will be made due to emergencies
10.00
 
DIAGNOSTICS
0120 Periodic oral examination No Charge
0140/
0150/
0160
Limited/Comprehensive oral evaluation No Charge
0180 Comprehensive oral evaluation 15.00
0210 X-Ray Intraoral - complete series including bitewings No Charge
0220 X-Ray Intraoral - periapical (first film) No Charge
0230 X-Ray Intraoral - periapical (each additional film) No Charge
0270 X-Ray Bitewings - single film No Charge
0272 X-Ray Bitewings - two films No Charge
0274 Bitewings - four films No Charge
0330 Panoramic film No Charge
0460 Pulp vitality tests No Charge
0470 Diagnostic casts No Charge
 
PREVENTIVE CARE
1110/
1120
Prophylaxis - adult/child (routine, once every 6 months) No Charge
1110/
1120
Prophylaxis - adult/child (additional ) 25.00
1201 Topical application of fluoride (including prophylaxis)
child (up to 16 years of age)
No Charge
1203 Topical application of fluoride (not including prophylaxis) child (up to 16 years of age) No Charge

 

1351 Sealant - per tooth 15.00
1330 Oral hygiene instruction No Charge
1510 Space Maintainer - fixed - unilateral 55 + LAB
1515 Space Maintainer - fixed - bilateral 55 + LAB
1520 Space Maintainer - removable - unilateral 95 + LAB
1525 Space Maintainer - removable - bilateral 95 + LAB
1550 Recementation of space maintainer 15.00
 
RESTORATIVE
2140 Amalgam - one surface, primary or permanent 20.00
2150 Amalgam - two surfaces, primary or permanent 25.00
2160 Amalgam - three surfaces, primary or permanent 30.00
2161 Amalgam - four or more surfaces, primary or permanent 40.00
2940 Sedative filling 20.00
2999 Sedative base (Under fillings), by report No Charge
 
RESIN RESTORATION
2330 Resin - one surface, anterior 40.00
2331 Resin - two surfaces, anterior 45.00
2332 Resin - three surfaces, anterior 55.00
2391 Resin - based composite - one surface, posterior 70.00
2392 Resin - based composite - two surfaces, posterior 90.00
2393 Resin - based composite - three surfaces, posterior 110.00
2394 Resin - based composite - four or more surfaces, posterior 130.00
2510 Inlay - metallic - one surface 115.00
2520 Inlay - metallic - two surfaces 125.00
2530 Inlay - metallic - three or more surfaces 150.00
 
CROWN & BRIDGE
2740 Crown - porcelain/ceramic substrate 310 + LAB
2750* Crown - porcelain fused to high noble metal 310.00
2751 Crown - porcelain fused to predominantly base metal 310.00
2752* Crown - porcelain fused to noble metal 310.00
2790* Crown - full cast high noble metal 310.00
2791 Crown - full cast predominantly base metal 310.00
2792* Crown - full cast noble metal 310.00
2910 Recement inlay  20.00
2920 Recement crown  20.00
2930 Prefabricated stainless steel crown - primary tooth 90.00
2950 Core buildup, including any pins 50.00
2951 Pin retention - per tooth 20.00
2952 Cast post and core in addition to crown 100 + LAB
2953 Each additional cast post - same tooth 100 + LAB
2954 Prefabricated post and core in addition to crown 100.00
2962 Labial veneer (porcelain laminate) - laboratory 310 + LAB
 
ENDODONTICS
3220 Therapeutic pulpotomy/pulpectomy 40.00
3221 Pulpal debridement, primary and permanent teeth 110.00
Root canals
3310 Root canal therapy - anterior (excluding final restoration) 150.00
3320 Root canal therapy - bicuspid (excluding final restoration) 250.00
3330 Root canal therapy - molar (excluding final restoration) 300.00
3410 Apicoectomy/periradicular surgery - anterior 150.00
 
PERIODONTICS (Gum Treatment)
4210 Gingivectomy/gingivoplasty
(4+ teeth per quad )
150.00
4211 Gingivectomy/gingivoplasty
(1-3 teeth per quad )
45.00
4260 Osseous surgery,
(4+ teeth, per quad )
375.00
4261 Osseous surgery,
(1-3 teeth, per quad )
375.00
4271 Free soft tissue graft procedure
(inc. donor site surgery)
250.00
4341 Periodontal scaling and root planning (4+ teeth per quad ) 55.00
4342 Periodontal scaling and root planning (1-3 teeth per quad) 55.00
4355 Full mouth debridement to enable evaluation and diagnosis 50.00
4381 Localized delivery of chemotherapeutic agents (per tooth) 50.00
4910 Periodontal maintenance 55.00
 
PROSTHODONTICS
5110 Complete denture - maxillary 325 + LAB
5120 Complete denture - mandibular 325 + LAB
5130 Immediate denture - maxillary 325 + LAB
5140 Immediate denture - mandibular 325 + LAB
5211 Maxillary partial denture - resin base 325 + LAB
5212 Mandibular partial denture - resin base 325 + LAB
5213 Maxillary partial denture - cast metal framework, resin denture bases 325 + LAB
5214 Mandibular partial denture - cast metal framework, resin denture bases 325 + LAB
5410 Adjust complete denture - maxillary 20.00
5411 Adjust complete denture - mandibular 20.00
5421 Adjust partial denture - maxillary 20.00
5422 Adjust partial denture - mandibular 20.00
 
REPAIRS TO PROSTHETICS
5510 Repair broken complete denture base 20 + LAB
5520 Replace missing or broken teeth - complete denture (each tooth) 20 + LAB
5610 Repair resin denture base 20 + LAB
5630 Repair or replace broken clasp 20 + LAB
5640 Replace broken teeth - per tooth 20 + LAB
5650 Add tooth to existing partial denture 35 + LAB
5730 Reline complete maxillary denture (chairside) 55.00
5731 Reline complete mandibular denture (chairside) 55.00
5740 Reline maxillary partial denture (chairside) 55.00
5741 Reline mandibular partial denture (chairside) 55.00
5750 Reline complete maxillary denture (laboratory)  40 + LAB
5751 Reline complete mandibular denture (laboratory)  40 + LAB
5760 Reline maxillary partial denture (laboratory)  40 + LAB
5761 Reline mandibular partial denture (laboratory)  40 + LAB
5850 Tissue conditioning - maxillary 35.00
5851 Tissue conditioning - mandibular 35.00
 
PROSTHODONTICS (Fixed)
6210* Pontic - cast high noble metal 310.00
6211 Pontic - cast predominantly base metal 310.00
6212* Pontic - cast noble metal 310.00
6240* Pontic - porcelain fused to high noble metal 310.00
6241 Pontic - porcelain fused to predominantly base metal 310.00
6242* Pontic - porcelain fused to noble metal 310.00
6750* Crown - porcelain fused to high noble metal 310.00
6751 Crown - porcelain fused to predominantly base metal 310.00
6752* Crown - porcelain fused to noble metal 310.00
6790* Crown - full cast high noble metal 310.00
6791 Crown - full cast predominantly base metal 310.00
6792* Crown - full cast noble metal 310.00
6930 Recement fixed partial denture (per unit) 15.00
 
EXTRACTIONS/ORAL AND MAXILLOFACIAL SURGERY
7111 Coronal remnants, deciduous tooth 25.00
7140 Extraction (erupted tooth or exposed root ) 25.00
7210 Surgical removal of erupted tooth 45.00
7220 Removal of impacted tooth - soft tissue  60.00
7230 Removal of impacted tooth - partially bony 80.00
7240 Removal of impacted tooth - completely bony 100.00
7250 Surgical removal of residual tooth roots 45.00
7310 Alveoloplasty in conjunction with extractions - per quadrant 45.00
7320 Alveoloplasty not in conjunction with extractions - per quadrant 80.00
7510 Incision and drainage of abscess - intraoral 30.00
 
ORTHODONTICS
8070/
8080
Comprehensive orthodontic treatment of the transitional/adolescent dentition.
  Children up to 19 years of age Up to 24 months of routine (full-banded) orthodontic treatment for Class I and Class II cases
  Consultation No Charge
  Evaluation 35.00
  Records/Treatment Planning 250.00
  Orthodontic Treatment 1,800.00
8090 Comprehensive orthodontic treatment of the adult dentition.
Adults 19 years of age and over
  Up to 24 months of routine (full-banded) orthodontic treatment for Class I and Class II cases
  Consultation No Charge
  Evaluation 35.00
  Records/Treatment Planning 250.00
  Orthodontic Treatment 2,000.00
8680 Retention 450.00
 
ADJUNCTIVE GENERAL SERVICES
9215 Local anesthesia No Charge
9230 Analgesia (nitrous oxide - per 15 minutes) 20.00
9450 Case presentation, detailed and extensive treatment planning No Charge
9951 Occlusal adjustment - limited 30.00
9952 Occlusal adjustment - complete 175.00
 
* THE ABOVE CO-PAYMENTS DO NOT INCLUDE THE ADDITIONAL COST OF PRECIOUS (HIGH NOBLE) AND SEMI-PRECIOUS (NOBLE) METAL.

THE ADDITIONAL COST OF PRECIOUS METAL SHALL NOT EXCEED 125 PER UNIT AND 75 PER UNIT FOR SEMI-PRECIOUS METAL.
 
NOTE:
  1. Not all participating dentists perform all listed procedures, including amalgams. Please consult your dentist prior to treatment for availability of services.
  2. Unlisted procedures are at the dentist's usual fee less 25%.
  3. When crown and/or bridgework exceeds six units in the same treatment plan, the patient may be charged an additional 50.00 per unit.
 
SPECIALIST SERVICES
Should you need a specialist, (i.e., Endodontist, Oral Surgeon, Periodontist, Pediatric Dentist), you may be referred by your Participating General Dentist, or you may refer yourself to any Participating Specialist. Co-payment amounts are applicable when treatment is performed by Participating Specialists. Benefits for procedures not listed on the schedule, that are performed by a Participating Specialist, are available at the Participating Specialist's usual and customary fee less 25%.
 

Limitations and Exclusions

  1. No service of any dentist other than a Participating General Dentist or Participating Specialist will be covered by Company, except out-of-area emergency care as provided in Section VIII, Paragraph C of the Certificate.
  2. Whenever any Contributions or Co-payments are delinquent, Member will not be entitled to receive Benefits, transfer Dental Facilities, or enjoy any of the other privileges of a Member in good standing.
  3. Company does not provide coverage for the following services:
 
a.    Cost of hospitalization and pharmaceuticals, drugs or medications.
 
b.    Services which in the opinion of the Participating General Dentist or Participating Specialist are not Necessary Treatment to establish and/or maintain the Member's oral health.
 
c.    Any service that is not consistent with the normal and/or usual services provided by the Participating General Dentist or Participating Specialist or which in the opinion of the Participating General Dentist or Participating Specialist would endanger the health of the Member.
 
d.    Any service or procedure which the Participating General Dentist or Participating Specialist is unable to perform because of the general health or physical limitations of the Member.
 
e.    Any dental treatment started prior to the Member's effective date for eligibility of benefits.
 
f.    Services for injuries and conditions which are paid or payable under Workers' Compensation or Employers' Liability laws.
 
g.    Treatment for cysts, neoplasms and malignancies.
 
h.    General anesthesia.
 

CompBenefits Family of Companies:

bulletCompDent
bulletCompBenefits Insurance Company
bulletAmerican Dental Plan, Inc.
bulletOral Health Services, Inc.
bulletAmerican Dental Plan of North Carolina, Inc.
bulletNational Dental Plans, Inc.
bulletTexas Dental Plans, Inc.
bulletVision Care, Inc.
bulletUltimate Optical, Inc.

 

 

 



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