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C-250 DHMO Schedule1
| 1Select a service below |
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| SERVICES |
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| RESIN RESTORATION |
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ADA
Code |
Procedure |
Member
Pays |
| 2330 |
Resin - one surface, anterior |
$40.00 |
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| 2331 |
Resin - two surfaces, anterior |
40.00 |
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| 2332 |
Resin - three surfaces, anterior |
55.00 |
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| 2391 |
Resin-based composite - one surface,
posterior |
70.00 |
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| 2392 |
Resin-based composite - two surfaces,
posterior |
90.00 |
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| 2393 |
Resin-based composite - three
surfaces, posterior |
110.00 |
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| 2394 |
Resin-based composite - four or more
surfaces, posterior |
130.00 |
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| 2510 |
Inlay - metallic - one surface |
115.00 |
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| 2520 |
Inlay - metallic - two surfaces |
125.00 |
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| 2530 |
Inlay - metallic - three or more
surfaces |
150.00 |
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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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