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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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| PERIODONTICS (Gum Treatment) |
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ADA
Code |
Procedure |
Member
Pays |
| 4210 |
Gingivectomy/gingivoplasty
(4+ teeth per quad) |
$150.00 |
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| 4211 |
Gingivectomy/gingivoplasty
(1-3 teeth per quad) |
45.00 |
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| 4341 |
Periodontal scaling and root planing
(4+ teeth per quad ) |
55.00 |
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| 4342 |
Periodontal scaling and root planing
(1-3 teeth per quad) |
55.00 |
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| 4355 |
Full mouth debridement to enable
evaluation and diagnosis |
50.00 |
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| 4381 |
Localized delivery of chemotherapeutic
agents (per tooth) |
50.00 |
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| 4910 |
Periodontal maintenance |
55.00 |
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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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