Download Plan CFDN70 - Baltimore City Public Schools

Plan CFDN70
The following is a complete listing of the Member Copayments:
ADA
0120
0140
0150
0170
0180
0210
0220
0230
0240
0270
0272
0274
0330
0340
0460
0470
0471
1110
1120
1208
1330
1351
1510
1515
1520
1525
1550
2140
2150
2160
2161
Procedure Name
Copay
CLINICAL ORAL EVALUATIONS
Periodic oral evaluation
Limited oral evaluation – problem focused
Comprehensive oral evaluation – new or established patient
Re-evaluation – limited, problem focused (established patient; not
post-operative visit)
Comprehensive periodontal evaluation – new or established
patient
RADIOGRAPHS
Intraoral - complete series of radiographic images
Intraoral - periapical first radiographic image
Intraoral - periapical each additional radiographic image
Intraoral - occlusal radiographic image
Bitewing - single radiographic image
Bitewings - two radiographic images
Bitewings - four radiographic images
Panoramic radiographic image
Cephalometric radiographic image
TESTS AND LABORATORY EXAMINATIONS
Pulp Vitality Tests
Diagnostic Casts
Diagnostic Photographs
DENTAL PROPHYLAXIS
Prophylaxis - Adult
Prophylaxis - Child
TOPICAL FLUORIDE TREATMENT
Topical application of fluoride
OTHER PREVENTIVE SERVICES
Oral Hygiene Instructions
Sealant – Per Tooth
SPACE MAINTENANCE (PASSIVE APPLIANCES)
Space Maintainer – Fixed Unilateral
Space Maintainer – Fixed Bilateral
Space Maintainer – Removable Unilateral
Space Maintainer – Removable Bilateral
Recementation of space maintainer
AMALGAM RESTORATIONS (INCLUDING POLISHING)
Amalgam – one surface, primary or permanent
Amalgam – two surfaces, primary or permanent
Amalgam – three surfaces, primary or permanent
Amalgam – four or more surfaces, primary or permanent
1
5
5
5
5
5
10
2
1
2
2
3
4
9
9
5
5
5
6
5
4
NC
2
68
112
55
112
18
24
31
40
48
DN70 1/14
ADA
2330
2331
2332
2335
2391
2392
2393
2394
2510
2520
2530
2543
2544
2610
2620
2710
2740
2750
2751
2752
2790
2791
2792
2799
2910
2920
2930
2931
2933
2940
2950
2951
2952
2953
2954
2957
2960
2961
2962
Procedure Name
Copay
RESIN RESTORATIONS
Resin - one surface, anterior
Resin - two surfaces, anterior
Resin - three surfaces, anterior
Resin - four or more surfaces or involving incisal angle (anterior)
Resin-based composite – one surface, posterior
Resin-based composite – two surfaces, posterior
Resin-based composite – three surfaces, posterior
Resin-based composite – four or more surfaces, posterior
INLAY/ONLY RESTORATIONS
Inlay – metallic – one surface
Inlay – metallic – two surfaces
Inlay – metallic – three or more surfaces
Onlays – metallic – three or more surfaces
Onlays – metallic – three or more surfaces
Inlay – porcelain/ceramic – one surface
Inlay – porcelain/ceramic – two surfaces
CROWNS – SINGLE RESTORATION ONLY
Crown – resin-based composite (indirect)
Crown – porcelain/ceramic substrate
Crown – porcelain fused to high noble metal
Crown – porcelain fused to predominately base metal
Crown – porcelain fused to noble metal
Crown – full cast high noble metal
Crown – full cast predominately base metal
Crown – full cast noble metal
Provisional crown – further treatment or completion of diagnosis
necessary prior to final impression
OTHER RESTORATIVE SERVICES
Recement inlay, only, or partial coverage restoration
Recement crown
Prefabricated stainless steel crown – primary tooth
Prefabricated stainless steel crown – permanent tooth
Prefabricated stainless steel crown with resin window
Sedative filling
Core buildup, including any pins
Pin retention – per tooth in addition to restoration
Cast post and core in addition to crown (cast post and core is
separate from crown)
Each additional cast post – same tooth (to be used with D2952)
Prefabricated post and core in addition to crown
Each additional prefabricated post – same tooth (to be used with
D2954)
Labial veneer (laminate) - chairside
Labial veneer (resin laminate) - laboratory
Labial veneer (porcelain laminate) - laboratory
2
27
38
47
66
27
38
47
66
84
165
210
50
75
300
325
122
273
338
318
328
338
318
328
80
13
21
70
88
100
23
60
8
88
44
60
30
112
210
250
DN70 1/14
ADA
3110
3120
3220
3230
3240
3310
3320
3330
3346
3347
3348
3410
3421
3425
3426
3430
3450
3910
3920
3950
4210
4211
4212
4240
4249
4260
4263
Procedure Name
Copay
PULP CAPPING
Pulp Cap – Direct (excluding final restoration)
Pulp Cap – Indirect (excluding final restoration)
PULPOTOMY
Therapeutic Pulpotomy (excluding final restoration)
ENDODONTIC THERAPY ON PRIMARY TEETH
Pupal therapy (resorbable filling) – anterior primary tooth
(excluding final restoration)
Pupal therapy (resorbable filling) – posterior primary tooth
(excluding final restoration)
ROOT CANAL / ENDODONTIC THERAPY (INCLUDING
TREATMENT PLAN, CLINICAL PROCEDURES AND
FOLLOW-UP CARE)
Anterior (excluding final restoration)
Bicuspid (excluding final restoration)
Molar (excluding final restoration)
ENDODONTIC RETREATMENT
Retreatment of previous root canal therapy - anterior
Retreatment of previous root canal therapy -bicuspid
Retreatment of previous root canal therapy - molar
APICOECTOMY/PERIAPICAL SERVICES
Apicoectomy/Periradicular surgery - anterior
Apicoectomy/Periradicular surgery – bicuspid (first root)
Apicoectomy/Periradicular surgery – molar (first root)
Apicoectomy/Periradicular surgery – (each additional root)
Retrograde Filling – per root
Root amputation – per root
OTHER ENDODONTIC PROCEDURES
Surgical procedure for isolation of tooth with rubber dam
Hemisection (incl. any root removal) not including root canal
therapy
Canal preparation and fitting of performed or post
SURGICAL SERVICES (INCLUDING USUAL POSTOPERATIVE SERVICES)
Gingivectomy or gingivoplasty – four or more contiguous teeth or
bounded teeth spaces per quadrant
Gingivectomy or gingivoplasty – one to three contiguous teeth or
bounded teeth spaces per quadrant
Gingivectomy or gingivoplasty to allow access for restorative
procedure, per toot
Gingival flap procedure, including root planning – four or more
contiguous teeth or bounded teeth spaces per quadrant
Clinical crown lengthening – hard tissue
Osseous surgery (including flap entry and closure) – four or more
contiguous teeth or bounded teeth spaces per quadrant
Bone replacement graft – first site in quadrant
3
11
5
49
80
95
180
245
350
255
320
425
198
205
215
50
25
84
90
111
65
200
45
45
157
180
360
91
DN70 1/14
ADA
4264
4270
4273
4274
4277
4278
4320
4321
4341
4342
4355
4910
5110
5120
5130
5140
5211
5212
5213
5214
5281
5410
5411
5421
5422
Procedure Name
Copay
Bone Replacement graft – each additional site in quadrant
Pedicle soft tissue graft procedure
Subepithelial connective tissue graft procedures, per tooth
Distal or proximal wedge procedure (when not performed in
conjunction with surgical procedures in the same anatomical area)
Free soft tissue graft procedure (including donor site surgery), first
tooth or edentulous tooth position in graft
Free soft tissue graft procedure (including donor site surgery), each
additional contiguous tooth or edentulous tooth position in same
graft site
ADJUNCTIVE PERIODONTAL SERVICES
Provisional splinting - intracoronal
Provisional splinting - extracoronal
Periodontal scaling and root planning – four or more teeth per
quadrant
Periodontal scaling and root planning – one to three teeth per
quadrant
Full mouth debridement to enable comprehensive evaluation and
diagnosis
OTHER PERIODONTAL SERVICES
Periodontal maintenance
COMPLETE DENTURES (Including Routine Post-Delivery
Care)
Complete denture - maxillary
Complete denture - mandibular
Immediate denture - maxillary
Immediate denture - mandibular
PARTIAL DENTURES (Including Routine Post-Delivery
Care)
Maxillary partial denture – resin base (including any conventional
clasps, rests and teeth)
Mandibular partial denture - resin base (including any
conventional clasps, rests and teeth)
Maxillary partial denture - cast metal framework with resin
denture bases (including any conventional clasps, rests and teeth)
Mandibular partial denture – cast metal framework with resin
denture bases (including any conventional clasps, rests and teeth)
Removable unilateral partial denture – one piece cast metal
(including clasps and teeth)
ADJUSTMENTS TO REMOVABLE PROSTHESIS
Adjust complete denture - maxillary
Adjust complete denture - mandibular
Adjust partial denture - maxillary
Adjust partial denture - mandibular
4
36
154
154
54
150
105
28
32
51
32
28
42
307
307
325
325
168
168
378
378
115
9
9
14
14
DN70 1/14
ADA
5510
5520
5610
5620
5630
5640
5650
5660
5710
5711
5720
5721
5730
5731
5740
5741
5750
5751
5760
5761
5810
5811
5820
5821
5850
5851
6210
6211
6212
6240
6241
6242
6545
6750
6751
6752
6780
6790
Procedure Name
Copay
REPAIRS TO COMPLETE DENTURES
Repair to broken complete denture base
Replace missing or broken teeth – complete denture (each tooth)
REPAIRS TO PARTIAL DENTURES
Repair resin denture base
Repair cast framework
Repair or replace broken clasp
Replace broken teeth – per tooth
Add tooth to existing partial denture
Add clasp to existing partial denture
DENTURE REBASE PROCEDURES
Rebase complete maxillary denture
Rebase complete mandibular denture
Rebase maxillary partial denture
Rebase mandibular partial denture
DENTURE RELINE PROCEDURES
Reline complete maxillary denture (chairside)
Reline complete mandibular denture (chairside)
Reline maxillary partial denture (chairside)
Reline mandibular partial denture (chairside)
Reline complete maxillary denture (laboratory)
Reline complete mandibular denture (laboratory)
Reline maxillary partial denture (laboratory)
Reline mandibular partial denture (laboratory)
OTHER REMOVABLE PROSTHETIC SERVICES
Interim complete denture (maxillary)
Interim complete denture (mandibular)
Interim partial denture (maxillary)
Interim partial denture (mandibular)
Tissue conditioning - maxillary
Tissue conditioning - mandibular
FIXED PARTIAL DENTURE PONTICS
Pontic – cast high noble metal
Pontic – cast predominately base metal
Pontic – cast noble metal
Pontic – porcelain fused to high noble metal
Pontic – porcelain fused to predominately base metal
Pontic – porcelain fused to noble metal
RETAINERS
Retainers – cast metal for resin bonded fixed prosthesis
FIXED PARTIAL DENTURE RETAINERS - CROWN
Crown – porcelain fused to high noble metal
Crown – porcelain fused to predominately base metal
Crown – porcelain fused to noble metal
Crown – 3/4 cast high noble metal
Crown –full cast high noble metal
5
42
35
38
42
31
35
45
66
110
110
50
50
49
49
49
49
73
73
73
73
175
175
88
88
45
45
338
318
328
338
318
328
126
338
318
328
338
338
DN70 1/14
ADA
6791
6792
6930
6940
6950
6971
7111
7140
7210
7220
7230
7240
7241
7250
7280
7286
7310
7320
7510
7520
7960
7971
8010
8020
8030
8040
8050
8060
8070
8080
8090
Procedure Name
Copay
Crown – full cast predominately base metal
Crown – full cast noble metal
OTHER FIXED PARTIAL DENTURE SERVICES
Replacement Fixed Partial Denture
Stress breaker
Precision attachment
Cast post as part of fixed partial denture retainer
EXTRACTIONS (Includes Local Anesthesia, Suturing, if
needed and Routine Post Operative Care)
Extraction, coronal remnants – deciduous tooth
Extraction, erupted tooth or exposed root (elevation and/or
forceps removal)
SURGICAL EXTRACTIONS (Includes Local Anesthesia,
Suturing, if needed and Routine Post Operative Care)
Surgical removal of erupted tooth requiring elevation of
mucoperiosteal flap and removal of bone and/or section of tooth
Removal of impacted tooth – soft tissue
Removal of impacted tooth – partially bony
Removal of impacted tooth – completely bony
Removal of impacted tooth – completely bony, with unusual
surgical complications
Surgical removal of residual tooth roots (cutting procedure)
OTHER SURGICAL PROCEDURES
Surgical access of an unerupted tooth
Biopsy of oral tissue - soft
ALVEOLOPLASTY – Surgical Preparation of Ridge for
Dentures
Alveoloplasty – in conjunction with extractions – per quadrant
Alveoloplasty – not in conjunction with extractions – per quadrant
SURGICAL INCISION
Incision and drainage of abscess – intraoral soft tissue
Incision and drainage of abscess – extraoral soft tissue
OTHER REPAIR PROCEDURES
Frenulectomy (frenectomy or frenotomy) – separate procedure
Excision of pericoronal gingiva
LIMITED ORTHODONTIC TREATMENT
Limited orth. treatment of the primary dentition
Limited orth. treatment of the transitional dentition
Limited orth. treatment of the adolescent dentition
Limited orth. treatment of the adult dentition
INTERCEPTIVE ORTHODONTIC TREATMENT
Interceptive orthodontic treatment of the primary dentition
Interceptive orthodontic treatment of the transitional dentition
COMPREHENSIVE ORTHODONTIC TREATMENT
Comprehensive orthodontic treatment of the transitional dentition
Comprehensive orthodontic treatment of the adolescent dentition
Comprehensive orthodontic treatment of the adult dentition
6
318
328
32
70
100
95
30
50
39
63
75
115
128
70
145
60
60
77
46
40
88
80
425
450
475
500
700
800
1950
1950
1950
DN70 1/14
ADA
8210
8220
8660
8670
8680
9110
9230
9241
9242
9310
9400
9910
9911
9940
9941
9950
9951
9952
9974
Procedure Name
Copay
MINOR TREATMENT TO CONTROL HARMFUL
HABITS
Removable appliance therapy
Fixed appliance therapy
OTHER ORTHODONTIC SERVICES
Pre-orthodontic treatment visit
Periodic orthodontic treatment visit (as part of contract)
Orthodontic retention (removal of appliances, construction and
placement of retainer(s))
UNCLASSIFIED TREATMENT
Palliative (emergency) treatment of dental pain – minor procedure
ANESTHESIA
Analgesia, anxiolysis, inhalation of nitrous oxide
Intravenous conscious sedation/analgesia – first 30 minutes
Intravenous conscious sedation/analgesia – each additional 15
minutes
PROFESSIONAL CONSULTATION
Consultation – (diagnostic service provided by dentist or
physician other than practitioner providing treatment)
PROFESSIONAL VISITS
Broken appointment charge – per 15 minutes (without 24 hours
prior notice)
MISCELLANEOUS SERVICES
Application of desensitizing medicament
Application of desensitizing resin for cervical and/or root surface,
per tooth
Occlusal guard, by report
Fabrication of athletic mouthguard
Occlusal analysis – mounted case
Occlusal adjustment - limited
Occlusal adjustment - complete
Internal bleaching – per tooth
195
175
100
75
175
4
28
88
30
15
10
7
7
130
5
Not Covered
46
119
145
NC – No Charge
7
DN70 1/14
PLAN LIMITATIONS – IN-NETWORK
Services for injuries and conditions which are covered under Workers’ Compensation or
Employers’ Liability Laws;
Services which are provided without cost to the Covered Individual by any municipality, county
or other political subdivision (with the exception of Medicaid);
Services which, in the opinion of the participating DENTIST, are not necessary for the covered
Individual’s health;
Payment of any claim or bill will not be made for prohibited referrals;
Cosmetic, elective, or aesthetic dentistry, which in the opinion of the participating DENTIST are
not necessary for the patient’s dental health;
Oral surgery requiring the setting of fractures or dislocations;
Services with respect to malignancies, cysts or neoplasms, or hereditary, congenital or
developmental malformations;
Dispensing of drugs, except those used as a local anesthetic;
Hospitalization for any dental procedure;
Loss or theft of bridgework or dentures previously supplied under the PLAN;
Replacement of a bridge, crown, or denture within five (5) years after the date it was originally
installed;
Any implantation;
General anesthesia;
Services that cannot be performed because of the general health of the patient;
Teeth Cleaning (Prophylaxis) limited to twice per calendar year;
Unlisted procedures will be provided at the dentist’s charges;
Services which are obtained outside the dental office in which enrolled and which are not preauthorized by the PLAN. This does not apply to out-of-area emergency dental services;
Services rendered by a Pedodontist (Pediatric Dentist) are considered Specialty Care and must be
approved by the Covered Individual’s General Participating DENTIST;
All services listed on the Schedule of Benefits and Member Copayments will be provided by a
general Participating Dentist or an approved Specialist; provided, however, that a general
DENTIST will refer the Covered Individual or Dependent to an approved Specialist or
recommend that the Covered Individual or Dependent contact an approved Specialist if it is the
judgment of the DENTIST that the service or procedure must be provided by an approved
Specialist, with an exception for out-of-area emergency care;
Services which cannot be performed in the dental office of the “Personal Participating
DENTIST” or “Approved Specialist” due to the special needs or health related conditions of the
Covered Employee and/or Dependent(s).
OUT-OF-AREA EMERGENCY CARE: Members are covered for emergency dental treatment to
alleviate acute pain, along with treatment arising from accidental injury or illness while temporarily
more than 50 miles from their regular place of residence and the nearest Plan Dental Office. Limited
to $50 per Member per emergency.
ALL PRICES ARE EXCLUSIVE OF GOLD
Not all services and procedures are covered by your dental benefits plan. This description is for comparison
purposes only and does not create rights not given through the Group benefit agreement.
8
DN70 1/14