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Download 2017 DHMO Dental Plan Schedule of Members` Payment
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DHMO PLAN 5000 (IL - $5 Office Visit Copay) SCHEDULE OF MEMBERS’ PAYMENT RESPONSIBILITY Effective as of 1/1/2017 DIAGNOSTIC D0999 D0120 D0140 D0145 D0150 D0160 D0170 D0171 D0180 D0210 D0220 D0230 D0240 D0270 D0272 D0273 D0274 D0277 D0330 D0415 D0460 D0470 D0600 Office Visit Copay ........................................................................................................ $5 Periodic Oral Evaluation .............................................................................................. $0 Limited Oral Evaluation - Problem Focused ............................................................... $0 Oral Eval for Patient under 3 & Counseling with Primary Caregiver .......................... $0 Comprehensive Oral Evaluation - New or Established Patient ................................... $0 Detailed & Extensive Evaluation, Problem Focused ................................................... $0 Re-Eval - Limited, Problem Focused (Est. Patient, Not Post-Operative) .................... $0 Re-Evaluation - Post-Operative Office Visit ................................................................ $0 Comprehensive Periodontal Examination, New or Established Patient ...................... $0 Intraoral - Complete Series (Incl. Bitewings) .............................................................. $0 Intraoral - Periapical First Film ................................................................................... $0 Intraoral - Periapical Each Additional Film ................................................................. $0 Intraoral - Occlusal Film .............................................................................................. $0 Bitewing - Single Film ................................................................................................. $0 Bitewing X-Rays - 2 Films ........................................................................................... $0 Bitewing X-Rays - 3 Films ........................................................................................... $0 Bitewing X-Rays - 4 Films ........................................................................................... $0 Vertical Bitewings - 7 to 8 Films ................................................................................. $0 Panoramic Film ........................................................................................................... $0 Bacteriological Studies ................................................................................................ $0 Pulp Vitality Tests ........................................................................................................ $0 Diagnostic Casts .......................................................................................................... $0 Non-ionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin and cementum .............................. $0 D1110 D1120 D1206 D1208 D1310 D1330 D1351 D1352 D1510 D1515 D1520 D1525 D1550 D1555 D1575 Prophylaxis - Adult ...................................................................................................... $0 Prophylaxis - Child ..................................................................................................... $0 Topical Fluoride Varnish, Therapeutic Application for Mod to High Caries Risk Patients ........................................................................................................................ $0 Topical Application Of Fluoride - Excluding Varnish .................................................. $0 Nutritional Counseling for Control of Dental Disease ................................................ $0 Oral Hygiene Instructions ............................................................................................ $0 Sealant - Per Tooth ...................................................................................................... $0 Preventive Resin Restoration in Mod - High Caries Risk Patient - Perm Tooth ......... $0 Space Maintainer - Fixed - Unilateral ....................................................................... $40 Space Maintainer - Fixed - Bilateral .......................................................................... $39 Space Maint-Removable - Unilateral ......................................................................... $27 Space Maint-Removable - Bilateral ........................................................................... $39 Re-cement or Re-bond Space Maintainer ................................................................... $6 Removal of a Space Maintainer, By Dentist Who Did Not Originally Place ................ $3 Distal shoe space maintainer - fixed - unilateral ....................................................... $40 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2929 D2990 Amalgam - 1 Surface, Primary or Permanent ........................................................... $19 Amalgam - 2 Surfaces, Primary or Permanent .......................................................... $23 Amalgam - 3 Surfaces, Primary or Permanent .......................................................... $26 Amalgam - 4 or More Surfaces, Primary or Permanent ............................................ $23 Resin-Based Composite - 1 Surface, Anterior .......................................................... $23 Resin-Based Composite - 2 Surfaces, Anterior ........................................................ $27 Resin-Based Composite - 3 Surfaces, Anterior ........................................................ $37 Resin-Based Comp - 4 or More Surfaces or Involving Incisal Angle (Anterior) ...... $41 Resin-Based Composite Crown, Anterior ................................................................. $44 Resin-Based Composite - 1 Surface, Posterior ........................................................ $27 Resin-Based Composite - 2 Surfaces, Posterior ....................................................... $36 Resin-Based Composite - 3 Surfaces, Posterior ....................................................... $42 Resin-Based Composite - 4 or More Surfaces, Posterior ......................................... $51 Prefabricated Porcelain/Ceramic Crown – Primary Tooth ........................................ $58 Resin Infiltration of Incipient Smooth Surface Lesions ............................................... $0 D3110 D3120 D3220 D3221 D3222 D3230 D3240 D3310 D3320 D3330 D3346 D3347 D3348 D3351 D3352 D3353 Pulp Cap - Direct (Excluding Final Restoration) ......................................................... $9 Pulp Cap - Indirect (Excluding Final Restoration) ...................................................... $8 Therapeutic Pulpotomy (Excluding Final Restoration) ............................................. $29 Pulpal Debridement, Primary & Permanent Teeth ....................................................... $9 Partial Pulpotomy for Apexogenesis – Perm. Tooth with Incomplete Root .............. $15 Pulp Therapy, Anterior Primary ................................................................................. $16 Pulp Therapy, Posterior Primary ............................................................................... $34 Endodontic Therapy, Anterior Tooth (Excluding Final Restoration) ........................ $113 Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration) ...................... $133 Endodontic Therapy, Molar (Excluding Final Restoration) ..................................... $135 Retreatment of Previous Root Canal Therapy - Anterior ........................................... $91 Retreatment of Previous Root Canal Therapy - Bicuspid ........................................ $105 Retreatment of Previous Root Canal Therapy - Molar ............................................. $127 Apexification/Recalcification Initial Visit ................................................................... $19 Apexification/Recalcification Interim Visit ................................................................. $13 Apexification/Recalcification Final Visit .................................................................... $44 PREVENTIVE D3410 D3421 D3425 D3426 D3427 D3430 D3450 D3920 D3950 Apicoectomy - Anterior .............................................................................................. $64 Apicoectomy - Bicuspid (First Root) ......................................................................... $77 Apicoectomy - Molar (First Root) .............................................................................. $80 Apicoectomy (Each Additional Root) ......................................................................... $29 Periradicular Surgery without Apicoectomy .............................................................. $61 Retrograde Filling - Per Root .................................................................................... $14 Root Amputation Per Root ......................................................................................... $37 Hemisection (Incl. Root Removal/Excludes Rct) ....................................................... $35 Canal Prep & Fit of Preformed Post (By Other Than Dentist Who Placed Post) ........ $3 D4210 D4211 D4212 Gingivectomy or Gingivoplasty - 4 or More Teeth Per Quadrant .............................. $49 Gingivectomy or Gingivoplasty - 1 to 3 Teeth, Per Quadrant ................................... $27 Gingivectomy or Gingivoplasty to Allow Access For Restorative Procedure, Per Tooth .......................................................................................................................... $13 Gingival Flap Procedure, w/Root Planing - 4 or More Teeth Per Quadrant .............. $58 Gingival Flap Procedure, w/Root Planing - 1 to 3 Teeth, Per Quadrant ................... $37 Apically Positioned Flap ............................................................................................ $56 Clinical Crown Lengthening - Hard Tissue ............................................................... $73 Osseous Surgery (Incl. Elevation of a Full Thickness Flap & Closure) - 4 or More Teeth Per Quad ............................................................................................... $110 Osseous Surgery (Incl. Elevation of a Full Thickness Flap & Closure) - 1 to 3 Teeth, Per Quad .......................................................................................................... $77 Bone replacement graft - retained natural tooth - first site in quadrant .................... $33 Bone replacement graft - retained natural tooth - each additional site in quadrant . $25 Surgical Revision Procedure, Per Tooth, Inclusive in Surgery ................................. $19 Pedicle Soft Tissue Graft Procedure .......................................................................... $71 Autogenous Connective Tissue Graft Procedure (Incl. Donor and Recipient Surgical Sites) First Tooth, Implant, or Edentulous Tooth Position in Graft ............. $96 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) ............................................ $24 Non-Autogenous Connective Tissue Graft (Incl. Recipient Site and Donor Material) First Tooth, Implant, or Edentulous Tooth Position in Graft ...................... $34 Combined Connective Tissue & Pedicle Graft .......................................................... $91 Free Soft Tissue Graft Procedure (Incl. Recipient and Donor Surgical Sites) First Tooth, Implant, or Edentulous Tooth Position in Graft .............................................. $82 Free Soft Tissue Graft Procedure (Incl. Recipient and Donor Surgical Sites) each additional Contiguous Tooth, Implant, or Edentulous Tooth Position in same Graft Site .................................................................................................................... $49 Autogenous Connective Tissue Graft Procedure (Incl. Donor and Recipient Surgical Sites) - each additional Contiguous Tooth, Implant or Edentulous Tooth Position in same Graft Site ........................................................................................ $57 Non-Autogenous Connective Tissue Graft Procedure (Incl. Recipient Surgical Site and Donor Material) - each additional Contiguous Tooth, Implant or Edentulous Tooth Position in same Graft Site ........................................................... $21 Scaling & Root Planing - 4 or More Teeth Per Quadrant .......................................... $38 Scaling & Root Planing - 1 to 3 Teeth, Per Quadrant ............................................... $23 Scaling in presence of generalized moderate or severe gingival inflammation full mouth, after oral evaluation .................................................................................. $0 Full Mouth Debridement to Enable Comprehensive Evaluation & Diagnosis .......... $24 Loc. Deliv. Chemo Agent, Controlled Release into Crevice, Per Tooth ....................... $8 Periodontal Maintenance ........................................................................................... $21 Gingival Irrigation - Per Quadrant ............................................................................... $4 PERIODONTICS D4240 D4241 D4245 D4249 D4260 D4261 D4263 D4264 D4268 D4270 D4273 D4274 D4275 D4276 D4277 D4278 D4283 D4285 MINOR RESTORATIVE ENDODONTICS D4341 D4342 D4346 D4355 D4381 D4910 D4921 ORAL SURGERY D7111 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7280 D7310 D7311 D7320 D7321 D7450 D7451 D7510 D7511 D7960 D7963 D7972 Extraction, Coronal Remnants - Deciduous Tooth .................................................... $14 Extraction, Erupted Tooth or Exposed Root (Elevation and/or Forceps Removal) .... $20 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated ..................................... $22 Removal of Impacted Tooth - Soft Tissue .................................................................. $28 Removal of Impacted Tooth - Partially Bony ............................................................. $38 Removal of Impacted Tooth - Completely Bony ........................................................ $46 Removal of Impacted Tooth - Completely Bony, with Unusual Surg Comp ............. $50 Removal of residual tooth roots (cutting procedure) ................................................ $38 Exposure of an unerupted tooth ................................................................................ $38 Alveoloplasty w/Extractions - Per Quadrant .............................................................. $19 Alveoloplasty w/Ext - 1 To 3 Teeth or Spaces, Per Quadrant .................................... $18 Alveoloplasty Not w/Extractions - Per Quadrant ....................................................... $24 Alveoloplasty Not w/Extractions - 1 to 3 Teeth or Spaces Per Quadrant .................. $18 Removal of Benign Odontogenic Cyst or Tumor (Diameter <= 1.25 Cm) ................. $31 Removal of Benign Odontogenic Cyst or Tumor (Diameter >1.25 Cm) .................... $36 Incision & Drainage of Abscess - Intraoral Soft Tissue ............................................ $15 Incision & Drainage of Abscess - Intraoral Soft Tissue - Complicated ...................... $9 Frenulectomy (Frenectomy or Frenotomy) - Separate Procedure ............................. $34 Frenuloplasty ............................................................................................................. $39 Surgical Reduction of Fibrous Tuberosity ................................................................. $20 IL-5000(5) 1/17 Page 1 of 3 DHMO PLAN 5000 (IL - $5 Office Visit Copay) CROWNS D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 D2643 D2644 D2650 D2651 D2652 D2662 D2663 D2664 D2710 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2910 D2915 D2920 D2930 D2931 D2932 D2933 D2934 D2940 D2941 D2949 D2950 D2951 D2952 D2953 D2954 D2957 D2971 D2980 Inlay - Metallic - 1 Surface* .................................................................................... $141 Inlay - Metallic - 2 Surfaces* .................................................................................. $168 Inlay - Metallic - 3 or More Surfaces* .................................................................... $181 Onlay - Metallic - 2 Surfaces* ................................................................................. $173 Onlay - Metallic - 3 Surfaces* ................................................................................. $204 Onlay - Metallic - 4 or More Surfaces* ................................................................... $212 Inlay - Porcelain Ceramic 1 Surf ............................................................................. $152 Inlay - Porcelain Ceramic 2 Surf ............................................................................. $169 Inlay - Porcelain Ceramic 3 Surf ............................................................................. $183 Onlay - Porcelain Ceramic 2 Surf ............................................................................ $177 Onlay - Porcelain Ceramic 3 Surf ............................................................................ $205 Onlay - Porcelain Ceramic 4+ Surf ......................................................................... $213 Inlay - Resin 1 Surf .................................................................................................. $132 Inlay - Resin 2 Surf .................................................................................................. $147 Inlay - Resin 3 Surf .................................................................................................. $159 Onlay - Resin 2 Surf ................................................................................................ $154 Onlay - Resin 3 Surf ................................................................................................ $178 Onlay - Resin 4+ Surf .............................................................................................. $186 Crown - Resin-Lab .................................................................................................... $80 Crown - Resin, High Noble Metal* ........................................................................ $121 Crown - Resin, Base Metal ...................................................................................... $121 Crown - Resin, Noble Metal ................................................................................... $121 Crown - Porcelain/Ceramic Substrate ..................................................................... $385 Crown - Porcelain Fused to High Noble Metal* ..................................................... $360 Crown - Porcelain Fused to Predominantly Base Metal ......................................... $320 Crown - Porcelain Fused to Noble Metal ................................................................ $368 Crown - 3/4 Cast High Noble Metal* ...................................................................... $220 Crown - 3/4 Cast Predominantly Base Metal .......................................................... $187 Crown - 3/4 Cast Noble Metal ................................................................................ $204 Crown - 3/4 Porcelain/Ceramic .............................................................................. $227 Crown - Full Cast High Noble Metal* ..................................................................... $360 Crown - Full Cast Predominantly Base Metal ......................................................... $187 Crown - Full Cast Noble Metal ................................................................................ $368 Crown - Titanium ..................................................................................................... $220 Re-cement or Re-bond Inlay, Onlay, Veneer or Partial Coverage Restoration ............ $7 Re-cement or Re-bond Indirectly Fabricated or Prefabricated Post & Core ............... $7 Re-cement or Re-bond Crown ................................................................................... $14 Prefabricated Stainless Steel Crown - Primary Tooth ............................................... $51 Prefabricated Stainless Steel Crown - Permanent Tooth ........................................... $56 Prefabricated Resin Crown ........................................................................................ $58 Prefabricated Stainless Steel Crown with Resin Window .......................................... $58 Prefabricated Esthetic Coated Stainless Steel Crown - Primary Tooth ..................... $58 Protective Restoration ................................................................................................ $15 Interim Therapeutic Restoration - Primary Dentition .................................................. $5 Restorative Foundation for an Indirect Restoration ................................................... $22 Core Buildup, Incl. any Pins When Required ............................................................ $95 Pin Retention - Per Tooth, in Addition to Restoration ............................................... $20 Cast Post & Core in Addition to Crown* ................................................................ $134 Each Additional Cast Post - Same Tooth* ................................................................. $42 Prefabricated Post & Core in Addition to Crown .................................................... $108 Each Additional Prefabricated Post - Same Tooth ....................................................... $5 Additional Procedures to Construct New Crown Under Existing Partial .................. $60 Crown Repair ............................................................................................................. $43 D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 Pontic - Indirect Resin Based Composite ................................................................. $80 Pontic - Cast High Noble Metal* ............................................................................. $335 Pontic - Cast Predominantly Base Metal ................................................................. $187 Pontic - Cast Noble Metal ....................................................................................... $204 Pontic - Titanium ..................................................................................................... $220 Pontic - Porcelain Fused to High Noble Metal* ...................................................... $314 Pontic - Porcelain Fused to Predominantly Base Metal .......................................... $335 Pontic - Porcelain Fused to Noble Metal ................................................................ $343 Pontic - Porcelain/Ceramic ..................................................................................... $343 Pontic - Resin, High Noble Metal* .......................................................................... $223 Pontic - Resin, Base Metal ...................................................................................... $197 Pontic - Resin, Noble Metal .................................................................................... $210 Retainer - Cast Metal for Resin Bonded Fixed Prosthesis* ...................................... $84 Retainer - Porcelain for Resin Bonded Prosthesis .................................................... $84 Resin Retainer - for Resin Bonded Fixed Prosthesis ................................................ $42 Retainer Inlay - Porcelain/Ceramic, Two Surfaces .................................................. $169 Retainer Inlay - Porcelain/Ceramic, Three or More Surfaces .................................. $183 Retainer Inlay - Cast High Noble Metal, Two Surfaces* .......................................... $168 Retainer Inlay - Cast High Noble Metal, Three or More Surfaces* ......................... $181 Retainer Inlay - Cast Predominately Base Metal, Two Surfaces .............................. $168 Retainer Inlay - Cast Predominately Base Metal, Three or More Surfaces ............. $181 Retainer Inlay - Cast Noble Metal, Two Surfaces .................................................... $168 Retainer Inlay - Cast Noble Metal, Three or More Surfaces .................................... $181 Retainer Onlay - Porcelain/Ceramic, Two Surfaces ................................................. $177 Retainer Onlay - Porcelain/Ceramic, Three or More Surfaces ................................ $205 Retainer Onlay - Cast High Noble Metal, Two Surfaces* ........................................ $173 FIXED BRIDGES D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6794 D6930 D6980 Retainer Onlay - Cast High Noble Metal, Three or More Surfaces* ........................ $204 Retainer Onlay - Cast Predominately Base Metal, Two Surfaces ............................ $173 Retainer Onlay - Cast Predominately Base Metal, Three or More Surfaces ............ $204 Retainer Onlay - Cast Noble Metal, Two Surfaces ................................................... $173 Retainer Onlay - Cast Noble Metal, Three or More Surfaces .................................. $204 Retainer Inlay - Titanium ......................................................................................... $168 Retainer Onlay - Titanium ........................................................................................ $173 Retainer Crown - Indirect Resin Based Composite ................................................... $80 Retainer Crown - Resin with High Noble Metal* ..................................................... $121 Retainer Crown - Resin with Predominately Base Metal ......................................... $121 Retainer Crown - Resin with Noble Metal ............................................................... $121 Retainer Crown - Porcelain/Ceramic ....................................................................... $385 Retainer Crown - Porcelain Fused to High Noble Metal* ....................................... $360 Retainer Crown - Porcelain Fused to Predominately Base Metal ........................... $360 Retainer Crown - Porcelain Fused to Noble Metal .................................................. $368 Retainer Crown - 3/4 Cast High Noble Metal* ........................................................ $217 Retainer Crown - 3/4 Cast Predominately Base Metal ............................................ $187 Retainer Crown - 3/4 Cast Noble Metal .................................................................. $204 Retainer Crown - 3/4 Porcelain/Ceramic ................................................................ $227 Retainer Crown - Full Cast High Noble Metal* ....................................................... $220 Retainer Crown - Full Cast Predominately Base Metal ........................................... $187 Retainer Crown - Full Cast Noble Metal .................................................................. $204 Retainer Crown - Titanium ...................................................................................... $220 Re-cement or Re-bond Fixed Partial Denture ........................................................... $11 Fixed Partial Denture Repair, by report ...................................................................... $42 D2960 D2961 D2962 Labial Veneer (Resin Laminate) - Chairside ............................................................ $322 Labial Veneer (Resin Laminate) - Lab ..................................................................... $458 Labial Veneer (Porcelain Laminate) - Lab ............................................................... $550 D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5221 D5222 D5223 D5224 D5225 D5226 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5670 D5671 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5850 D5851 Complete Denture - Maxillary ................................................................................. $485 Complete Denture - Mandibular .............................................................................. $485 Immediate Denture - Maxillary ................................................................................ $518 Immediate Denture - Mandibular ............................................................................ $518 Maxillary Partial - Resin Base ................................................................................. $485 Mandibular Partial - Resin Base .............................................................................. $485 Maxillary Partial - Cast Metal Framework w/Resin Bases ....................................... $518 Mandibular Partial - Cast Metal Framework w/Resin Bases ................................... $518 Immediate Maxillary Partial - Resin Base ............................................................... $509 Immediate Mandibular Partial - Resin Base ............................................................ $509 Immediate Maxillary Partial - Cast Metal Framework w/Resin Bases ..................... $544 Immediate Mandibular Partial - Cast Metal Framework w/Resin Bases ................. $544 Maxillary Partial - Flexible Base .............................................................................. $305 Mandiublar Partial - Flexible Base ......................................................................... $305 Removable Unilateral Partial Denture ...................................................................... $121 Adjust Complete Denture - Maxillary ........................................................................ $14 Adjust Complete Denture - Mandibular .................................................................... $14 Adjust Partial Denture - Maxillary ............................................................................. $14 Adjust Partial Denture - Mandibular ......................................................................... $23 Repair Broken Complete Denture Base ..................................................................... $58 Replace Missing or Broken Teeth - Complete Denture (Each Tooth) ........................ $55 Repair Resin Denture Base ........................................................................................ $67 Repair Cast Framework .............................................................................................. $32 Repair or Replace Broken Clasp - Per Tooth ............................................................. $80 Replace Broken Teeth - Per Tooth ............................................................................. $52 Add Tooth to Existing Partial Denture ....................................................................... $68 Add Clasp to Existing Partial Denture - Per Tooth .................................................... $86 Replace All Teeth & Acrylic on Cast Metal Framework - Maxillary ......................... $114 Replace All Teeth & Acrylic on Cast Metal Framework - Mandibular ..................... $114 Rebase Complete Maxillary Denture ......................................................................... $99 Rebase Complete Mandibular Denture ...................................................................... $99 Rebase Maxillary Partial Denture .............................................................................. $92 Rebase Mandibular Partial Denture ......................................................................... $179 Reline Complete Maxillary Denture (Chairside) ........................................................ $48 Reline Complete Mandibular Denture (Chairside) .................................................... $48 Reline Maxillary Partial Denture (Chairside) ............................................................. $39 Reline Mandibular Partial Denture (Chairside) ......................................................... $39 Reline Complete Maxillary Denture (Laboratory) ...................................................... $83 Reline Complete Mandibular Denture (Laboratory) ................................................ $156 Reline Maxillary Partial Denture (Laboratory) ........................................................... $72 Reline Mandibular Partial Denture (Laboratory) ....................................................... $72 Tissue Conditioning, Maxillary ................................................................................. $46 Tissue Conditioning, Mandibular .............................................................................. $27 D8080 Comprehensive Orthodontic Treatment of the Adolescent Dentition (age 18 and under) Class I and II ............................................................................................ $3,241 Comprehensive Orthodontic Treatment of the Adult Dentition (age 19 and over) Class I and II ........................................................................................................ $3,621 Pre-Orthodontic Treatment Examination to Monitor Growth and Development ..... $205 Orthodontic Retention (Removal of Appliances, Construction & Placement Of Retainer(s)) .............................................................................................................. $255 Removable Orthodontic Retainer Adjustment .............................................................. $0 LABIAL VENEERS DENTURES ORTHODONTICS D8090 D8660 D8680 D8681 IL-5000(5) 1/17 Page 2 of 3 DHMO PLAN 5000 (IL - $5 Office Visit Copay) SCHEDULE OF MEMBERS’ PAYMENT RESPONSIBILITY Effective as of 1/1/2017 MISCELLANEOUS D9110 D9210 D9215 D9219 D9223 D9230 D9310 D9311 D9430 D9440 D9450 D9910 D9911 D9951 D9952 D9991 D9992 D9993 D9994 Palliative (Emergency) Treatment of Dental Pain - Minor Procedure ....................... $11 Local Anesthetic, Not in Conjunction with Operative Procs. ...................................... $0 Local Anesthesia-In Conjunction with Operative or Surgical Procedures (Inclusive in those Procedures) ................................................................................................... $0 Evaluation for Deep Sedation or General Anesthesia ................................................ $21 Deep Sedation/General Anesthesia - Each 15 Minute Increment ............................. $55 Analgesia, Nitrous Oxide ............................................................................................. $9 Consultation - Diagnostic Service Provided by Dentist or Physician Other Than Requesting Dentist or Physician ............................................................................... $10 Consultation with a medical health care professional ................................................. $0 Office Visit for Observation (During Regularly Scheduled Hours) .............................. $5 Office Visit for Observation (After Regularly Scheduled Hours) ................................. $5 Case Presentation, Detailed & Extensive Treatment Planning .................................... $0 Application of Desensitizing Medicament, Per Visit ................................................... $4 Application of Desensitizing Resin for Cervical and/or Root Surface-Per Tooth ........ $5 Occlusal Adjustment - Limited .................................................................................... $9 Occlusal Adjustment - Complete ............................................................................... $27 Dental case management - addressing appointment compliance barriers ................. $0 Dental case management - care coordination ............................................................. $0 Dental case management - motivational interviewing ................................................. $0 Dental case management - patient education to improve oral health literacy ............ $0 *Designated restorations include high noble metal (gold). The actual cost of this metal may be added to the patient’s responsibility at the time of service. The payment responsibilities listed above are valid as of January 1, 2017. The payment responsibilities are subject to revision on January 1 of each year. A complete description of benefits, limitations and exclusions is included in your subscription certificate. Current Dental Terminology © 2015 American Dental Association. All rights reserved. IL-5000(5) 1/17 Page 3 of 3
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