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CS-150 DHMO Schedule1

1Select a service below
 
SERVICES
 
bulletAppointments
bulletDiagnostics
bulletPreventive Care
bullet Restorative
bulletResin Restoration
bulletCrown & Bridge
bulletEndodontics
bulletPeriodontics
bullet Prosthodontics
bulletRepairs to Prosthetics
bulletProsthodontics (Fixed)
bulletExtractions
bulletOrthodontics
bulletAdjunctive General Service
 
REPAIRS TO PROSTHETICS
ADA
Code		 Procedure Member
Pays
5510 Repair broken complete denture base $15 + LAB
5520 Replace missing or broken teeth - complete denture (each tooth) 15 + LAB
5610 Repair resin denture base 15 + LAB
5630 Repair or replace broken clasp 15 + LAB
5640 Replace broken teeth - per tooth 15 + LAB
5650 Add tooth to existing partial denture 30 + LAB
5730 Reline complete maxillary denture (chairside) 50.00
5731 Reline complete mandibular denture (chairside) 50.00
5740 Reline maxillary partial denture (chairside) 50.00
5741 Reline mandibular partial denture (chairside) 50.00
5750 Reline complete maxillary denture (laboratory) 35 + LAB
5751 Reline complete mandibular denture (laboratory) 35 + LAB
5760 Reline maxillary partial denture (laboratory)  35 + LAB
5761 Reline mandibular partial denture (laboratory)  35 + LAB
5850 Tissue conditioning - maxillary 30.00
5851 Tissue conditioning - mandibular 30.00
 
*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
  1. Not all participating dentists perform all listed procedures, including amalgams. Please consult your dentist prior to treatment for availability of services.
  2. Unlisted procedures are at the dentist's usual fee less 25%.
  3. 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%.
 
 

 

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