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Jackson Memorial Hospital
Dental Members |
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ADP Enriched Plan Schedule of Benefits1
The co-payments listed below are the maximum fees that will be charged by
the Participating General Dentist for the specified covered services.
| 1Select a service below |
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| Services |
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| Restorative Services |
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ADA
Code |
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Procedure |
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Member
Pays |
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| 2999 |
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Sedative base (Under fillings) |
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No Charge |
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| Amalgam (silver) |
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2110/
2140 |
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One surface |
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No Charge |
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2120/
2150 |
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Two surfaces |
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No Charge |
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2130/
2160 |
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Three surfaces |
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No Charge |
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2131/
2161 |
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Four or more surfaces |
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No Charge |
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| Resin Restoration (including acid etch,
glass ionomer liner) |
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| 2330 |
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Anterior one surface |
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12.00 |
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| 2331 |
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Anterior two surfaces |
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20.00 |
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| 2332 |
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Anterior three surfaces |
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25.00 |
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| 2510 |
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Inlay - metallic (one surfaces) |
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85.00 |
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| 2520 |
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Inlay - metallic (two surfaces) |
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95.00 |
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| 2530 |
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Inlay - metallic (three surfaces) |
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120.00 |
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| 2540 |
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Onlay - metallic (per tooth) (in addition
to inlay) |
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150.00 |
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| 2951 |
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Pin retention (per tooth) |
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12.00 |
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Note
- When crown and/or bridgework exceeds six consecutive units,
the patient may be charged an additional $25.00 per unit.
- All procedures listed may not be performed
by the Participating General Dentist you select. The co-payments shown
apply to those American Dental Plan Participating Dentists who do perform
those services. Therefore, you are encouraged to discuss availability
of the scheduled services with your Participating General Dentist. Procedures
not listed on the schedule of benefits, that are performed by the selected
Participating General Dentist will be charged at that Participating
General Dentist's usual and customary fee less 25%.
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Specialists
Should you need a specialist
(i.e. Endodontist, Orthodontist, Oral Surgeon, Periodontist, Prosthodontist,
Pediatric Dentist), you may be referred by your Participating General
Dentist. Co-payment amounts are applicable when treatment is performed
by selected Participating General Dentist or by Participating Specialists.
Benefits for procedures not listed on the schedule of benefits, that
are performed by a Participating Specialist, are available at the Participating
Specialist's usual and customary fee less 25%. |
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