Charlotte County Public Schools


 

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  CS150 DHMO Schedule of Benefits

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CS150 Schedule1

1Select a service below
 
SERVICES
bulletAppointments
bulletDiagnostics
bulletPreventive Care
bulletRestorative
bulletResin Restoration
bulletCrown & Bridge
bulletEndodontics
bulletPeriodontics
bulletProsthodontics
bulletRepairs to Prosthetics
bulletProsthodontics (Fixed)
bulletExtractions
bulletOrthodontics
bulletAdjunctive General Service
 
bulletLimitations and Exclusions
 
PERIODONTICS (Gum Treatment)
ADA
Code
Procedure Member
Pays
4210 Gingivectomy/gingivoplasty - per quadrant 125.00
4211 Gingivectomy/gingivoplasty - per tooth 40.00
4220 Gingival curettage - per quadrant 70.00
4260 Osseous surgery - per quadrant 350.00
4271 Free soft tissue graft procedure (inc. donor site surgery) 225.00
4341 Periodontal scaling and root planing - per quadrant 50.00
4355 Full mouth debridement 45.00
4381 Localized delivery of chemotherapeutic agents (per tooth) 45.00
4910 Periodontal maintenance procedures (following active therapy) 50.00
4999 Complete periodontal probing and treatment plan 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
  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%.
 

 

 

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