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Option II - Comprehensive Managed Dental
Care Plan (CS150) Schedule

 

  CS-150 Premier DHMO Schedule
ADA
CODE
Procedure Member Pays
 
APPOINTMENTS
9310 Consultation
(diagnostic service provided by dentist other than practitioner providing treatment)
15.00
9430 Office visit (normal hours) 5.00
9440 Office visit (after regularly scheduled hours) 35.00
9999 Emergency visit during regularly scheduled hours, by report 20.00
9999 Broken appointments
(without 24 hr notice, per 15 min.)

Maximum $40 per broken appointment. No Charge will be made due to emergencies
10.00
 
DIAGNOSTICS
0120 Periodic oral examination No Charge
0140/
0150/
0160
Limited/Comprehensive oral evaluation No Charge
0180 Comprehensive oral evaluation 10.00
0210   X-Ray Intraoral - complete series including bitewings   No Charge
0220   X-Ray Intraoral - periapical (first film)   No Charge
0230   X-Ray Intraoral - periapical
(each additional film)
  No Charge
0270 X-Ray Bitewings - single film No Charge
0272 X-Ray Bitewings - two films No Charge
0274 Bitewings - four films No Charge
0330 Panoramic film No Charge
0460 Pulp vitality tests No Charge
0470 Diagnostic casts No Charge
 
PREVENTIVE CARE
1110/
1120
  Prophylaxis - adult/child (routine, once every 6 months)   No Charge
1110/
1120
  Prophylaxis - adult/child (additional )   20.00
1201   Topical application of fluoride (including prophylaxis)
child (up to 16 years of age)
  No Charge
1203   Topical application of fluoride
(not including prophylaxis)
child (up to 16 years of age)
  No Charge

 

1351 Sealant - per tooth 10.00
1330 Oral hygiene instruction No Charge

 

1510   Space Maintainer - fixed - unilateral   45 + LAB
1515   Space Maintainer - fixed - bilateral   45 + LAB
1520   Space Maintainer - removable - unilateral   85 + LAB
1525   Space Maintainer - removable - bilateral   85 + LAB
1550   Recementation of space maintainer   10.00
 
RESTORATIVE
2140   Amalgam - one surface, primary or permanent   No Charge
2150   Amalgam - two surfaces, primary or permanent   No Charge
2160   Amalgam - three surfaces, primary or permanent   No Charge
2161   Amalgam - four or more surfaces, primary or permanent   No Charge
2940   Sedative filling   15.00
2999   Sedative base (under fillings), by report   No Charge
 
RESIN RESTORATION
2330   Resin - one surface, anterior   35.00
2331   Resin - two surfaces, anterior   40.00
2332   Resin - three surfaces, anterior   50.00
2391   Resin - based composite - one surface, posterior   60.00
2392   Resin - based composite - two surfaces, posterior   80.00
2393   Resin - based composite - three surfaces, posterior   100.00
2394   Resin - based composite - four or more surfaces, posterior   120.00
2510   Inlay - metallic - one surface   95.00
2520   Inlay - metallic - two surfaces   105.00
2530   Inlay - metallic - three or more surfaces   130.00
 
CROWN & BRIDGE
2740   Crown - porcelain/ceramic substrate   280 + LAB
2750*   Crown - porcelain fused to high noble metal   280.00
2751   Crown - porcelain fused to predominantly base metal   280.00
2752*   Crown - porcelain fused to noble metal   280.00
2790*   Crown - full cast high noble metal   280.00
2791   Crown - full cast predominantly base metal   280.00
2792*   Crown - full cast noble metal   280.00
2910   Recement inlay    15.00
2920   Recement crown   15.00
2930   Prefabricated stainless steel crown - primary tooth   75.00
2950   Core buildup, including any pins   45.00
2951   Pin retention - per tooth   15.00
2952   Cast post and core in addition to crown   90 + LAB
2953   Each additional cast post - same tooth   90 + LAB
2954   Prefabricated post and core in addition to crown   90.00
2962   Labial veneer (porcelain laminate) - laboratory   280 + LAB
 
ENDODONTICS
3220   Therapeutic pulpotomy/pulpectomy   35.00
3221   Pulpal debridement, primary and permanent teeth   100.00
  Root canals  
3310   Root canal therapy - anterior (excluding final restoration)   100.00
3320   Root canal therapy - bicuspid (excluding final restoration)   200.00
3330   Root canal therapy - molar (excluding final restoration)   250.00
3410   Apicoectomy/periradicular surgery - anterior   125.00
 
PERIODONTICS (Gum Treatment)
4210   Gingivectomy/gingivoplasty
(4+ teeth per quad )
  125.00
4211   Gingivectomy/gingivoplasty
(1-3 teeth per quad )
  40.00
4260   Osseous surgery,
(4+ teeth, per quad )
  350.00
4261   Osseous surgery,
(1-3 teeth, per quad )
  350.00
4271   Free soft tissue graft procedure
(inc. donor site surgery)
  225.00
4341   Periodontal scaling and root planning (4+ teeth per quad )   50.00
4342   Periodontal scaling and root planning (1-3 teeth per quad)   50.00
4355   Full mouth debridement to enable evaluation and diagnosis   45.00
4381   Localized delivery of chemotherapeutic agents (per tooth)   45.00
4910   Periodontal maintenance   50.00
ADA
CODE
Procedure Member Pays
 
PROSTHODONTICS
5110   Complete denture - maxillary   300 + LAB
5120   Complete denture - mandibular   300 + LAB
5130   Immediate denture - maxillary   300 + LAB
5140   Immediate denture - mandibular   300 + LAB
5211   Maxillary partial denture - resin base   300 + LAB
5212   Mandibular partial denture - resin base   300 + LAB
5213   Maxillary partial denture - cast metal framework, resin denture bases   300 + LAB
5214   Mandibular partial denture - cast metal framework, resin denture bases   300 + LAB
5410   Adjust complete denture - maxillary   15.00
5411   Adjust complete denture - mandibular   15.00
5421   Adjust partial denture - maxillary   15.00
5422   Adjust partial denture - mandibular   15.00
 
REPAIRS TO PROSTHETICS
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
 
PROSTHODONTICS (Fixed)
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
 
EXTRACTIONS/ORAL AND MAXILLOFACIAL SURGERY
7111   Coronal remnants, deciduous tooth   No Charge
7140   Extraction
(erupted tooth or exposed root )
  No Charge
7210   Surgical removal of erupted tooth   40.00
7220   Removal of impacted tooth - soft tissue    50.00
7230   Removal of impacted tooth - partially bony   70.00
7240   Removal of impacted tooth - completely bony   85.00
7250   Surgical removal of residual tooth roots   35.00
7310   Alveoloplasty in conjunction with extractions - per quadrant   35.00
7320   Alveoloplasty not in conjunction with extractions - per quadrant   70.00
7510   Incision and drainage of abscess - intraoral   25.00
 
ORTHODONTICS
8070/
8080
  Comprehensive orthodontic treatment of the transitional/adolescent dentition.
    Children up to 19 years of age
Up to 24 months of routine (full-banded) orthodontic treatment for
Class I and Class II cases
    Consultation   No Charge
    Evaluation   35.00
    Records/Treatment Planning   250.00
    Orthodontic Treatment   1,800.00
8090   Comprehensive orthodontic treatment of the adult dentition.
Adults 19 years of age and over
    Up to 24 months of routine (full-banded) orthodontic treatment for
Class I and Class II cases
    Consultation   No Charge
    Evaluation   35.00
    Records/Treatment Planning   250.00
    Orthodontic Treatment   2,000.00
8680   Retention   450.00
 
ADJUNCTIVE GENERAL SERVICES
9215   Local anesthesia   No Charge
9230   Analgesia
(nitrous oxide - per 15 minutes)
  15.00
9450   Case presentation, detailed and extensive treatment planning   No Charge
9951   Occlusal adjustment - limited   25.00
9952   Occlusal adjustment - complete   150.00
 
* 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%.
 
 

CompBenefits Family of Companies:

 
bulletCompDent
bulletCompBenefits Insurance Company
bulletAmerican Dental Plan, Inc.
bulletOral Health Services, Inc.
bulletAmerican Dental Plan of North Carolina, Inc.
bulletNational Dental Plans, Inc.
bulletTexas Dental Plans, Inc.
bulletVision Care, Inc.
bulletUltimate Optical, Inc.
 

Limitations and Exclusions

 
  1. No service of any dentist other than a Participating General Dentist or Participating Specialist will be covered by Company, except out-of-area emergency care as provided in Section VIII, Paragraph C of the Certificate.
     
  2. Whenever any Contributions or Co-payments are delinquent, Member will not be entitled to receive Benefits, transfer Dental Facilities, or enjoy any of the other privileges of a Member in good standing.
     
  3. Company does not provide coverage for the following services:
 
a.    Cost of hospitalization and pharmaceuticals, drugs or medications.
 
b.    Services which in the opinion of the Participating General Dentist or Participating Specialist are not Necessary Treatment to establish and/or maintain the Member's oral health.
 
c.    Any service that is not consistent with the normal and/or usual services provided by the Participating General Dentist or Participating Specialist or which in the opinion of the Participating General Dentist or Participating Specialist would endanger the health of the Member.
 
d.    Any service or procedure which the Participating General Dentist or Participating Specialist is unable to perform because of the general health or physical limitations of the Member.
 
e.    Any dental treatment started prior to the Member's effective date for eligibility of benefits.
 
f.    Services for injuries and conditions which are paid or payable under Workers' Compensation or Employers' Liability laws.
 
g.    Treatment for cysts, neoplasms and malignancies.
 
h.    General anesthesia.

 

Current Dental Terminology © 2004 American Dental Association. All rights reserved

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