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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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| EXTRACTIONS/ORAL AND MAXILLOFACIAL
SURGERY |
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ADA
Code |
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Procedure |
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Member
Pays |
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| 7111 |
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Coronal remnants, deciduous tooth |
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No Charge |
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| 7140 |
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Extraction
(erupted tooth or exposed root ) |
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No Charge |
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| 7210 |
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Surgical removal of erupted tooth |
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40.00 |
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| 7220 |
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Removal of impacted tooth - soft tissue |
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50.00 |
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| 7230 |
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Removal of impacted tooth - partially
bony |
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70.00 |
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| 7240 |
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Removal of impacted tooth - completely
bony |
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85.00 |
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| 7250 |
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Surgical removal of residual tooth
roots |
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35.00 |
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| 7310 |
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Alveoloplasty in conjunction with
extractions - per quadrant |
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35.00 |
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| 7320 |
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Alveoloplasty not in conjunction with
extractions - per quadrant |
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70.00 |
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| 7510 |
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Incision and drainage of abscess -
intraoral |
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25.00 |
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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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