 |
|
ADP Total Source
Dental Members |
|
|
 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
| |
|
|
CS-150 DHMO Schedule1
| 1Select a service below |
| |
| SERVICES |
| |
|
|
|
|
| |
| PROSTHODONTICS (FIXED) |
|
|
|
ADA
Code |
Procedure |
Member
Pays |
| 6210* |
Pontic - cast high noble metal |
$280.00 |
|
| 6211 |
Pontic - cast predominantly base metal |
280.00 |
|
| 6212* |
Pontic - cast noble metal |
280.00 |
|
| 6240* |
Pontic - porcelain fused to high noble
metal |
280.00 |
|
| 6241 |
Pontic - porcelain fused to
predominantly base metal |
280.00 |
|
| 6242* |
Pontic - porcelain fused to noble metal |
280.00 |
|
| 6750* |
Crown - porcelain fused to high noble
metal |
280.00 |
|
| 6751 |
Crown - porcelain fused to
predominantly base metal |
280.00 |
|
| 6752* |
Crown - porcelain fused to noble metal |
280.00 |
|
| 6790* |
Crown - full cast high noble metal |
280.00 |
|
| 6791 |
Crown - full cast predominantly base
metal |
280.00 |
|
| 6792* |
Crown - full cast noble metal |
280.00 |
|
| 6930 |
Recement fixed partial denture
(per unit) |
10.00 |
|
| |
*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. |
| |
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.
|
| |
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%. |
| |
| |
|
