Charlotte County Public Schools


 

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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
 
RESIN RESTORATION
ADA
Code
Procedure Member
Pays
2330 Resin - one surface, anterior $35.00
2331 Resin - two surfaces, anterior 40.00
2332 Resin - three surfaces, anterior 50.00
2380 Resin - one surface, posterior - primary 60.00
2381 Resin - two surfaces, posterior - primary 80.00
2382 Resin - three or more surfaces, posterior - primary 100.00
2385 Resin - one surface, posterior - permanent 60.00
2386 Resin - two surfaces, posterior - permanent 80.00
2387

Resin - three surfaces, posterior - permanent

100.00
2388 Resin - four or more surfaces, posterior - permanent 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
 
*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