DHMO Certificate of Benefits - Lake County

ADA CODE PROCEDURE PATIENT PAYS ADA CODE PROCEDURE PATIENT PAYSPROSTHODONTICS (Fixed)6210* Pontic - cast high noble metal .........$280.006211 Pontic - cast predominantly basemetal .........................................$280.006212* Pontic - cast noble metal ................$280.006240* Pontic - porcelain fused tohigh noble metal ..........................$280.006241 Pontic - porcelain fused topredominantly base metal ..............$280.006242* Pontic - porcelain fused tonoble metal .................................$280.006750* Crown - porcelain fused tohigh noble metal ..........................$280.006751 Crown - porcelain fused topredominantly base metal ..............$280.006752* Crown - porcelain fused to noblemetal .........................................$280.006790* Crown - full cast high noble metal ...$280.006791 Crown - full cast predominantlybase metal ..................................$280.006792* Crown - full cast noble metal ..........$280.006930 Recement fixed partial denture(per unit) .......................................$10.00EXTRACTIONS/ORAL AND MAXILLOFACIALSURGERY7111 Coronal remnants, deciduoustooth ....................................NO CHARGE7140 Extraction, erupted tooth orexposed root .........................NO CHARGE7210 Surgical removal of erupted tooth ......$40.007220 Removal of impacted tooth -soft tissue ......................................$50.007230 Removal of impacted tooth -partially bony ................................$70.007240 Removal of impacted tooth -completely bony .............................$85.007250 Surgical removal of residual toothroots ............................................$35.007310 Alveoloplasty in conjunction withextractions - per quadrant ................$35.007311 Alveoplasty in conjunction withextractions - one to three teeth ortooth spaces, per quadrant ...................$357320 Alveoloplasty not in conjunction withextractions - per quadrant ................$70.007321 Alveoplasty not in conjunction withextractions - one to three teeth ortooth spaces, per quadrant ...................$707510 Incision and drainage of abscess -intraoral ........................................$25.00ORTHODONTICS8070/8080Comprehensive orthodontic treatmentof the transitional/adolescent dentition.Children up to 19 years of age Up to 24months of routine (full-banded) orthodontictreatment for Class I and Class II casesConsultation ..........................NO CHARGEEvaluation .....................................$35.00Records/Treatment Planning ...........$250.00Orthodontic Treatment ................$1,800.008090 Comprehensive orthodontic treatmentof the adult dentition. Adults 19 years ofage and over Up to 24 months of routine(full-banded) orthodontic treatment forClass I and Class II casesConsultation ..........................NO CHARGEEvaluation .....................................$35.00Records/Treatment Planning ...........$250.00Orthodontic Treatment ................$2,000.008680 Retention .....................................$450.00ADJUNCTIVE GENERAL SERVICES9215 Local anesthesia ....................NO CHARGE9230 Analgesia (nitrous oxide -per 15 minutes) .............................$15.009450 Case presentation, detailed andextensive treatment planning .....NO CHARGE9951 Occlusal adjustment - limited ............$25.009952 Occlusal adjustment - complete .......$150.00* THE ABOVE COPAYMENTS DO NOT INCLUDE THEADDITIONAL COST OF PRECIOUS (HIGH NOBLE) ANDSEMI-PRECIOUS (NOBLE) METAL. THE ADDITIONALCOST OF PRECIOUS METAL SHALL NOT EXCEED $125PER UNIT AND $75 PER UNIT FOR SEMI-PRECIOUSMETAL.NOTE:1. NOT ALL PARTICIPATING DENTISTS PERFORM ALL LISTEDPROCEDURES, INCLUDING AMALGAMS. PLEASECONSULT YOUR DENTIST PRIOR TO TREATMENT FORAVAILABILITY OF SERVICES.2. UNLISTED PROCEDURES ARE AT THE DENTIST’S USUALFEE LESS 25%.3. WHEN CROWN AND/OR BRIDGEWORK EXCEEDSSIX UNITS IN THE SAME TREATMENT PLAN, THEPATIENT MAY BE CHARGED AN ADDITIONAL $50.00PER UNIT.CS150 03/03005CS1504Current Dental Terminology © 2004 American Dental Association. All rights reserved.