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ADP Total Source
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CS-150 DHMO Schedule1
| 1Select a service below |
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| SERVICES |
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| CROWN & BRIDGE |
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ADA
Code |
Procedure |
Member
Pays |
| 2740 |
Crown - porcelain/ceramic substrate |
$280 + LAB |
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| 2750* |
Crown - porcelain fused to high noble
metal |
280.00 |
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| 2751 |
Crown - porcelain fused to
predominantly base metal |
280.00 |
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| 2752* |
Crown - porcelain fused to noble metal |
280.00 |
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| 2790* |
Crown - full cast high noble metal |
280.00 |
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| 2791 |
Crown - full cast predominantly base
metal |
280.00 |
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| 2792* |
Crown - full cast noble metal |
280.00 |
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| 2910 |
Recement inlay |
15.00 |
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| 2920 |
Recement crown |
15.00 |
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| 2930 |
Prefabricated stainless steel crown -
primary tooth |
75.00 |
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| 2950 |
Core buildup, including any pins |
45.00 |
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| 2951 |
Pin retention - per tooth |
15.00 |
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| 2952 |
Cast post and core in addition to crown |
90 + LAB |
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| 2953 |
Each additional cast post - same tooth |
90 + LAB |
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| 2954 |
Prefabricated post and core in addition
to crown |
90.00 |
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| 2962 |
Labial veneer (porcelain laminate) -
laboratory |
280 + LAB |
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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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