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City of Delray Beach
Dental Members |
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CS150 DHMO Schedule1
| 1Select a service below |
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| SERVICES |
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| DIAGNOSTICS |
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ADA
Code |
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Procedure |
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Member
Pays |
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| 0120 |
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Periodic oral examination |
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No Charge |
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0140/
0150/
0160 |
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Limited/Comprehensive oral evaluation |
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No Charge |
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| 0180 |
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Comprehensive oral evaluation |
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10.00 |
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| 0210 |
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X-Ray Intraoral - complete series
including bitewings |
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No Charge |
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| 0220 |
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X-Ray Intraoral - periapical (first film) |
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No Charge |
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| 0230 |
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X-Ray Intraoral - periapical
(each additional
film) |
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No Charge |
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| 0270 |
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X-Ray Bitewings - single film |
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No Charge |
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| 0272 |
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X-Ray Bitewings - two films |
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No Charge |
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| 0274 |
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Bitewings - four films |
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No Charge |
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| 0330 |
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Panoramic film |
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No Charge |
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| 0460 |
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Pulp vitality tests |
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No Charge |
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| 0470 |
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Diagnostic casts |
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No Charge |
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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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