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ADP Total Source
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C-250 DHMO Schedule1
| 1Select a service below |
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| SERVICES |
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| DIAGNOSTICS |
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ADA
Code |
Procedure |
Member
Pays |
| 0120 |
Periodic oral examination |
No Charge |
|
0140/
0150/
0160 |
Limited/Comprehensive oral evaluation |
No Charge |
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| 0180 |
Comprehensive periodontal evaluation |
$15.00 |
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| 0210 |
X-Ray Intraoral - complete series
including bitewings |
No Charge |
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| 0220 |
X-Ray Intraoral - periapical (first film) |
No Charge |
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| 0230 |
X-Ray Intraoral - periapical
(each additional
film) |
No Charge |
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| 0270 |
X-Ray Bitewings - single film |
No Charge |
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| 0272 |
X-Ray Bitewings - two films |
No Charge |
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| 0274 |
Bitewings - four films |
No Charge |
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| 0330 |
Panoramic film |
No Charge |
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| 0460 |
Pulp vitality tests |
No Charge |
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| 0470 |
Diagnostic casts |
No Charge |
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*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. |
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Note
- Not all participating dentists perform all listed procedures,
including amalgams. Please consult your dentist prior to treatment for availability of services.
- Unlisted procedures are at the dentist's usual fee less 25%.
- When crown and/or bridgework exceeds six units in the same
treatment plan, the patient may be charged an additional 50.00 per
unit.
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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%. |
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