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| Dallas Independent School
District Dental Member | | | | | | | | | | | | | | | | | | | | |
Texas Dental Plan (TDP) Schedule1
| 1Select a service below | | | | SERVICES | | | | | | | | | | | | | | | | PERIODONTIC DENTISTRY (Gum Treatment) | | | | | | | ADA
Code | | Procedure | | Member
Pays |  | | D4250 | | Mucogingival Surgery - per quadrant | | $350 | | | | D4260 | | Osseous surgery (including flap entry and closure) - per quadrant | | 480 | | | | D4341 | | Periodontal scaling and root planning - per quadrant | | 65 | | | | D4910 | | Periodontal maintenance procedures (following active therapy) | | 48 | | | | | | At the diagnostic evaluation appointment, the participating general dentist will explain the treatment procedure and the fees. The above periodontic charges are our reduced fees for usual and customary periodontal services. Any periodontal treatment that requires tooth resection, gingival grafts, or other services will have an additional charge at a reduced rate. Discuss this with the dentist prior to beginning treatment. | | | All of the listed charges are reduced fees for services performed by a participating general dentist. Fees are subject to change without notice.
Any procedure not listed is available on a fee for service basis at a 20% discount. Consult with your participating general dentist prior to beginning any treatment. | | | Specialist Services
Any treatment provided by a participating specialist, if available, in Endodontics (root canal), Pediatric Dentistry (children's dentistry), Prosthodontics (Dentures), Orthodontics (teeth straightening), Periodontics (gum disease treatment) or Oral Surgery, will be charged at a 20% reduction of participating specialist's fees for that particular case. Some specialists may require a consultation visit before treatment is initiated. Discuss each case with the specialist prior to beginning any treatment. | | | |
