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OHS Standard 200 Plan Schedule of Benefits1

The co-payments listed are the maximum fees that will be charged by the Participating General Dentist for the specified covered services.

1Select a service below
Services
bulletAppointments
bulletDiagnostics
bulletX-Rays
bulletPreventive
bulletRestorative
bulletOral Surgery
bulletCrowns and Bridges
bulletEndodontics
bulletPeriodontics
bulletProsthetics
bulletOrthodontics
bulletLimitations and Exclusions

 

Oral Surgery Services
 
Procedure

Member
Pays

7110 Extraction single tooth No Charge
7120 Extraction each additional tooth $10
7210 Surgical extraction of erupted tooth 15
7220 Extraction - soft tissue impaction 25
7230 Extraction - partial bony impaction 50
7240 Extraction - full bony impaction 75
7250 Surgical extraction of residual root
(root recovery)
25
7999 Dry socket treatment No Charge
7470 Removal of exostosis
(tuberosity reduction)
60
7310/
7320
Alveolectomy or alveoloplasty
(per quadrant)
40
7510 Incision and drainage of intra-oral abscess No Charge
7970 Excision of hyperplastic tissue No Charge
7280 Surgical exposure of impacted or
unerupted tooth for orthodontic reasons
20
7960 Frenectomy 45
Post operative treatment No Charge


Note
The co-payments listed are the maximum fees that will be charged by the Participating General Dentist for the specified covered services.
 
Should you need a specialist (i.e., Endodontist, Orthodontist, Oral Surgeon, Periodontist, Prosthodontist, Pediatric Dentist), you may refer yourself to any Participating Specialist from our directory, Upon identifying yourself as an American Dental Plan member, you will receive a 25% reduction from usual and customary fees for services performed.
 
All procedures listed may not be performed by the Participating General Dentist. Therefore, you are encouraged to discuss availability of the scheduled services with your Participating General Dentist.
 
Specialist services are available only in areas where American Dental plan has a Participating Specialist.
 

 

 

Current Dental Terminology © 2004 American Dental Association. All rights reserved

 

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