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CS150 Schedule1
| 1Select a service below |
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| SERVICES |
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| ORTHODONTICS |
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ADA
Code |
Procedure |
Member
Pays |
8070/
8080 |
Comprehensive orthodontic treatment of
the transitional/adolescent dentition. |
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Children up to 19 years of
age
Up to 24 months of routine (full-banded) orthodontic treatment
for Class I and Class II cases |
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Consultation |
No Charge |
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Evaluation |
$35.00 |
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Records/Treatment Planning |
250.00 |
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Orthodontic Treatment |
1,800.00 |
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| 8090 |
Comprehensive orthodontic
treatment of the adult dentition.
Adults 19 years of age and over |
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Up to 24 months of routine
(full-banded) orthodontic treatment
for Class I and Class II cases |
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Consultation |
No Charge |
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Evaluation |
35.00 |
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Records/Treatment Planning |
250.00 |
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Orthodontic Treatment |
2,000.00 |
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| 8680 |
Retention |
450.00 |
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*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. |
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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.
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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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