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CS150 DHMO Schedule
| DIAGNOSTICS |
Top |
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ADA
Code |
Procedure |
Member
Pays |
| 0120 |
Periodic oral examination |
No Charge |
0140/
0150/
0160 |
Limited/Comprehensive oral evaluation |
No Charge |
 |
| 0180 |
Comprehensive oral evaluation |
10.00 |
|
|
| 0210 |
X-Ray Intraoral - complete series
including bitewings |
No Charge |
|
|
| 0220 |
X-Ray Intraoral - periapical (first film) |
No Charge |
|
|
| 0230 |
X-Ray Intraoral - periapical
(each additional
film) |
No Charge |
|
|
| 0270 |
X-Ray Bitewings - single film |
No Charge |
|
|
| 0272 |
X-Ray Bitewings - two films |
No Charge |
|
|
| 0274 |
Bitewings - four films |
No Charge |
|
|
| 0330 |
Panoramic film |
No Charge |
|
|
| 0460 |
Pulp vitality tests |
No Charge |
|
|
| 0470 |
Diagnostic casts |
No Charge |
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| PREVENTIVE CARE |
Top |
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ADA
Code |
Procedure |
Member
Pays |
1110/
1120 |
Prophylaxis - adult/child (routine, once every 6 months) |
No Charge |
|
|
1110/
1120 |
Prophylaxis - adult/child (additional) |
20.00 |
|
|
| 1201 |
Topical application of fluoride (including prophylaxis) child (up to 16 years of age) |
No Charge |
|
|
| 1203 |
Topical application of fluoride (not including prophylaxis) child (up to 16 years of age) |
No Charge |
|
|
| 1351 |
Sealant - per tooth |
10.00 |
|
|
| 1330 |
Oral hygiene instruction |
No Charge |
|
|
| 1510 |
Space Maintainer - fixed - unilateral |
45 + LAB |
|
|
| 1515 |
Space Maintainer - fixed - bilateral |
45 + LAB |
|
|
| 1520 |
Space Maintainer - removable -
unilateral |
85 + LAB |
|
|
| 1525 |
Space Maintainer - removable -
bilateral |
85 + LAB |
|
|
| 1550 |
Recementation of space maintainer |
10.00 |
|
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| RESTORATIVE |
Top |
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|
ADA
Code |
Procedure |
Member
Pays |
| 2140 |
Amalgam - one surface, primary or
permanent |
No Charge |
|
|
| 2150 |
Amalgam - two surfaces, primary or
permanent |
No Charge |
|
|
| 2160 |
Amalgam - three surfaces, primary or
permanent |
No Charge |
|
|
| 2161 |
Amalgam - four or more surfaces,
primary or permanent |
No Charge |
|
|
| 2940 |
Sedative filling |
15.00 |
|
|
| 2999 |
Sedative base (Under fillings), by
report |
No Charge |
|
|
| |
| RESIN RESTORATION |
Top |
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|
ADA
Code |
Procedure |
Member
Pays |
| 2330 |
Resin - one surface, anterior |
35.00 |
|
|
| 2331 |
Resin - two surfaces, anterior |
40.00 |
|
|
| 2332 |
Resin - three surfaces, anterior |
50.00 |
|
|
| 2391 |
Resin - based composite - one surface,
posterior |
60.00 |
|
|
| 2392 |
Resin - based composite - two surfaces,
posterior |
80.00 |
|
|
| 2393 |
Resin - based composite - three
surfaces, posterior |
100.00 |
|
|
| 2394 |
Resin - based composite - four or more
surfaces, posterior |
95.00 |
|
|
| 2510 |
Inlay - metallic - one surface |
95.00 |
|
|
| 2520 |
Inlay - metallic - two surfaces |
105.00 |
|
|
| 2530 |
Inlay - metallic - three or more
surfaces |
130.00 |
|
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| |
| CROWN & BRIDGE |
Top |
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ADA
Code |
Procedure |
Member
Pays |
| 2740 |
Crown - porcelain/ceramic substrate |
280 + LAB |
|
|
| 2750* |
Crown - porcelain fused to high noble
metal |
280.00 |
|
|
| 2751 |
Crown - porcelain fused to
predominantly base metal |
280.00 |
|
|
| 2752* |
Crown - porcelain fused to noble metal |
280.00 |
|
|
| 2790* |
Crown - full cast high noble metal |
280.00 |
|
|
| 2791 |
Crown - full cast predominantly base
metal |
280.00 |
|
|
| 2792* |
Crown - full cast noble metal |
280.00 |
|
|
| 2910 |
Recement inlay |
15.00 |
|
|
| 2920 |
Recement crown |
15.00 |
|
|
| 2930 |
Prefabricated stainless steel crown -
primary tooth |
75.00 |
|
|
| 2950 |
Core buildup, including any pins |
45.00 |
|
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| 2951 |
Pin retention - per tooth |
15.00 |
|
|
| 2952 |
Cast post and core in addition to crown |
90 + LAB |
|
|
| 2953 |
Each additional cast post - same tooth |
90 + LAB |
|
|
| 2954 |
Prefabricated post and core in addition
to crown |
90.00 |
|
|
| 2962 |
Labial veneer (porcelain laminate) -
laboratory |
280 + LAB |
|
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| |
| ENDODONTICS |
Top |
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|
ADA
Code |
Procedure |
Member
Pays |
| 3220 |
Therapeutic pulpotomy/pulpectomy |
35.00 |
|
|
| 3221 |
Pulpal debridement, primary and
permanent teeth |
100.00 |
|
|
| Root canals |
|
|
| 3310 |
Root canal therapy - anterior
(excluding final restoration) |
100.00 |
|
|
| 3320 |
Root canal therapy - bicuspid
(excluding final restoration) |
200.00 |
|
|
| 3330 |
Root canal therapy - molar (excluding
final restoration) |
250.00 |
|
|
| 3410 |
Apicoectomy/periradicular surgery -
anterior |
125.00 |
|
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| |
| PERIODONTICS (Gum Treatment) |
Top |
|
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ADA
Code |
Procedure |
Member
Pays |
| 4210 |
Gingivectomy/gingivoplasty
(4+ teeth per quad ) |
125.00 |
|
|
| 4211 |
Gingivectomy/gingivoplasty
(1-3 teeth per quad ) |
40.00 |
|
|
| 4260 |
Osseous surgery,
(4+ teeth, per quad ) |
350.00 |
|
|
| 4261 |
Osseous surgery,
(1-3 teeth, per quad ) |
350.00 |
|
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| 4271 |
Free soft tissue graft procedure
(inc. donor site surgery) |
225.00 |
|
|
| 4341 |
Periodontal scaling and root planning
(4+ teeth per quad ) |
50.00 |
|
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| 4342 |
Periodontal scaling and root planning
(1-3 teeth per quad) |
50.00 |
|
|
| 4355 |
Full mouth debridement to enable
evaluation and diagnosis |
45.00 |
|
|
| 4381 |
Localized delivery of chemotherapeutic
agents (per tooth) |
45.00 |
|
|
| 4910 |
Periodontal maintenance |
50.00 |
|
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| |
| PROSTHODONTICS |
Top |
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|
ADA
Code |
Procedure |
Member
Pays |
| 5110 |
Complete denture - maxillary |
300 + LAB |
|
|
| 5120 |
Complete denture - mandibular |
300 + LAB |
|
|
| 5130 |
Immediate denture - maxillary |
300 + LAB |
|
|
| 5140 |
Immediate denture - mandibular |
300 + LAB |
|
|
| 5211 |
Maxillary partial denture - resin base |
300 + LAB |
|
|
| 5212 |
Mandibular partial denture - resin base |
300 + LAB |
|
|
| 5213 |
Maxillary partial denture - cast metal
framework, resin denture bases |
300 + LAB |
|
|
| 5214 |
Mandibular partial denture - cast metal
framework,
resin denture bases |
300 + LAB |
|
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| 5410 |
Adjust complete denture - maxillary |
15.00 |
|
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| 5411 |
Adjust complete denture - mandibular |
15.00 |
|
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| 5421 |
Adjust partial denture - maxillary |
15.00 |
|
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| 5422 |
Adjust partial denture - mandibular |
15.00 |
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| REPAIRS TO PROSTHETICS |
Top |
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|
ADA
Code |
Procedure |
Member
Pays |
| 5510 |
Repair broken complete denture base |
15 + LAB |
|
|
| 5520 |
Replace missing or broken teeth -
complete denture (each tooth) |
15 + LAB |
|
|
| 5610 |
Repair resin denture base |
15 + LAB |
|
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| 5630 |
Repair or replace broken clasp |
15 + LAB |
|
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| 5640 |
Replace broken teeth - per tooth |
15 + LAB |
|
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| 5650 |
Add tooth to existing partial denture |
30 + LAB |
|
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| 5730 |
Reline complete maxillary denture (chairside) |
50.00 |
|
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| 5731 |
Reline complete mandibular denture (chairside) |
50.00 |
|
|
| 5740 |
Reline maxillary partial denture (chairside) |
50.00 |
|
|
| 5741 |
Reline mandibular partial denture (chairside) |
50.00 |
|
|
| 5750 |
Reline complete maxillary denture
(laboratory) |
35 + LAB |
|
|
| 5751 |
Reline complete mandibular denture
(laboratory) |
35 + LAB |
|
|
| 5760 |
Reline maxillary partial denture
(laboratory) |
35 + LAB |
|
|
| 5761 |
Reline mandibular partial denture
(laboratory) |
35 + LAB |
|
|
| 5850 |
Tissue conditioning - maxillary |
30.00 |
|
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| 5851 |
Tissue conditioning - mandibular |
30.00 |
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| PROSTHODONTICS (Fixed) |
Top |
|
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|
ADA
Code |
Procedure |
Member
Pays |
| 6210* |
Pontic - cast high noble metal |
280.00 |
|
|
| 6211 |
Pontic - cast predominantly base metal |
280.00 |
|
|
| 6212* |
Pontic - cast noble metal |
280.00 |
|
|
| 6240* |
Pontic - porcelain fused to high noble
metal |
280.00 |
|
|
| 6241 |
Pontic - porcelain fused to
predominantly base metal |
280.00 |
|
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| 6242* |
Pontic - porcelain fused to noble metal |
280.00 |
|
|
| 6750* |
Crown - porcelain fused to high noble
metal |
280.00 |
|
|
| 6751 |
Crown - porcelain fused to
predominantly base metal |
280.00 |
|
|
| 6752* |
Crown - porcelain fused to noble metal |
280.00 |
|
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| 6790* |
Crown - full cast high noble metal |
280.00 |
|
|
| 6791 |
Crown - full cast predominantly base
metal |
280.00 |
|
|
| 6792* |
Crown - full cast noble metal |
280.00 |
|
|
| 6930 |
Recement fixed partial denture
(per unit) |
10.00 |
|
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| |
| EXTRACTIONS/ORAL AND
MAXILLOFACIAL SURGERY |
Top |
|
|
|
ADA
Code |
Procedure |
Member
Pays |
| 7111 |
Coronal remnants, deciduous tooth |
No Charge |
|
|
| 7140 |
Extraction
(erupted tooth or exposed root ) |
No Charge |
|
|
| 7210 |
Surgical removal of erupted tooth |
40.00 |
|
|
| 7220 |
Removal of impacted tooth - soft tissue |
50.00 |
|
|
| 7230 |
Removal of impacted tooth - partially
bony |
70.00 |
|
|
| 7240 |
Removal of impacted tooth - completely
bony |
85.00 |
|
|
| 7250 |
Surgical removal of residual tooth
roots |
35.00 |
|
|
| 7310 |
Alveoloplasty in conjunction with
extractions - per quadrant |
35.00 |
|
|
| 7320 |
Alveoloplasty not in conjunction with
extractions - per quadrant |
70.00 |
|
|
| 7510 |
Incision and drainage of abscess -
intraoral |
25.00 |
|
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| |
| ORTHODONTICS |
Top |
|
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|
ADA
Code |
Procedure |
Member
Pays |
8070/
8080 |
Comprehensive orthodontic treatment of
the transitional/adolescent dentition. |
| |
Children up to 19 years of
age
Up to 24 months of routine (full-banded) orthodontic treatment
for Class I and Class II cases |
|
|
| |
Consultation |
No Charge |
|
|
| |
Evaluation |
35.00 |
|
|
| |
Records/Treatment Planning |
250.00 |
|
|
| |
Orthodontic Treatment |
1,800.00 |
|
|
| 8090 |
Comprehensive orthodontic
treatment of the adult dentition.
Adults 19 years of age and over |
| |
Up to 24 months of routine
(full-banded) orthodontic treatment
for Class I and Class II cases |
| |
Consultation |
No Charge |
|
|
| |
Evaluation |
35.00 |
|
|
| |
Records/Treatment Planning |
250.00 |
|
|
| |
Orthodontic Treatment |
2,000.00 |
|
|
| 8680 |
Retention |
450.00 |
|
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| ADJUNCTIVE GENERAL SERVICES |
Top |
|
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|
ADA
Code |
Procedure |
Member
Pays |
| 9215 |
Local anesthesia |
No Charge |
|
| 9230 |
Analgesia (nitrous oxide - per 15 minutes) |
15.00 |
|
|
| 9450 |
Case presentation, detailed and extensive treatment planning |
No Charge |
|
|
| 9951 |
Occlusal adjustment - limited |
25.00 |
|
|
| 9952 |
Occlusal adjustment - complete |
150.00 |
|
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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. |
| |
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.
|
| |
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%. |
| |
Note
When crown and/or bridgework
exceeds six consecutive units, the patient may be charged an additional
$25.00 per unit. |
| |
Limitations and Exclusions |
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- No service of any dentist other than a Participating General Dentist
or Participating Specialist will be covered by Company, except out-of-area
emergency care as provided in Section VIII, Paragraph C of the Certificate.
- Whenever any Contributions or Co-payments are delinquent, Member will not be
entitled to receive Benefits, transfer Dental Facilities, or enjoy
any of the other privileges of a Member in good standing.
- Company does not provide coverage for the following services:
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