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C-250 DHMO Schedule1
| 1Select a service below |
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| SERVICES |
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| PREVENTIVE CARE |
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ADA
Code |
Procedure |
Member
Pays |
1110/
1120 |
Prophylaxis - adult/child-routine (once every 6 months) |
No Charge |
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1110/
1120 |
Prophylaxis - adult/child (additional) |
$25.00 |
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| 1201 |
Topical application of fluoride (including prophylaxis) child (up to 16 years of age) |
No Charge |
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| 1203 |
Topical application of fluoride (not including prophylaxis) child (up to 16 years of age) |
No Charge |
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| 1330 |
Oral hygiene instruction |
No Charge |
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| 1351 |
Sealant - per tooth |
15.00 |
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| 1510 |
Space Maintainer - fixed - unilateral |
55 + LAB |
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| 1515 |
Space Maintainer - fixed - bilateral |
55 + LAB |
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| 1520 |
Space Maintainer - removable -
unilateral |
95 + LAB |
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| 1525 |
Space Maintainer - removable -
bilateral |
95 + LAB |
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| 1550 |
Recementation of space maintainer |
15.00 |
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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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