Download Member Dental Fees Texas

Member Dental Fees
Texas
Dental Discount Plan
Member’s Services
Member Pays
Diagnostic and Preventive Dentistry
D0120
Periodic oral evaluation.............................................................................................15
D0150
Comprehensive oral evaluation ...............................................................................15
D0210
Intraoral - complete series (including bitewings) .....................................................30
D0220
Intraoral - periapical - first film....................................................................................5
D0230
Intraoral - periapical each additional film ...................................................................4
D0270
Bitewing - single film...................................................................................................5
D0330
Panoramic film ......................................................................................................... 30
D0460
Pulp vitality tests ...................................................................................................... 12
D0470
Diagnostic casts....................................................................................................... 20
D1110
Prophylaxis - adult ................................................................................................... 29
D1120
Prophylaxis - child.................................................................................................... 29
D1351
Sealant - per tooth.................................................................................20% Discount
(Patients who have not had regular cleanings may require gum treatment)
D4355
Full mouth debridement to enable comprehensive periodontal evaluation and
diagnosis....................................................................................................................45
D9310
Consultation (diagnostic service provided by dentist or physician other
than practitioner providing treatment)......................................................15/10-Ortho
D9999
Infection control fee ................................................................................................... 9
**Infection control guidelines have been established by OSHA and the American Dental Association.
Infection control measures will be charged routinely by a participating dental office.
Cosmetic and Restorative Dentistry
Permanent and “Baby” Teeth
Amalgam Restorations (Silver Fillings)
D2110
Amalgam - one surface, primary..............................................................................34
D2120
Amalgam - two surfaces, primary ............................................................................44
D2130
Amalgam - three surfaces, primary..........................................................................54
D2140
Amalgam - one surface, permanent ........................................................................34
D2150
Amalgam - two surfaces, permanent.......................................................................44
D2160
Amalgam - three surfaces, permanent ....................................................................54
Resin Fillings (Tooth Colored)
D2330
Resin - based composite - one surface, anterior....................................................34
D2331
Resin - based composite - two surfaces, anterior ..................................................44
D2332
Resin - based composite - three surfaces, anterior................................................54
D2380
Resin - based composite - one surface, posterior primary.................20% Discount
D2381
Resin - based composite - two surfaces, posterior primary...............20% Discount
D2382
Resin - based composite - three surfaces, posterior primary.............20% Discount
D2385
Resin - based composite - one surface, posterior permanent ...........20% Discount
D2386
Resin - based composite - two surfaces, posterior permanent .........20% Discount
D2387
Resin - based composite - three surfaces, posterior permanent .......20% Discount
D2388
Resin - based composite - four/more surfaces,
posterior permanent ..............................................................................20% Discount
D2951
Pin retention - per tooth, in addition to restoration .................................................16
Crown and Bridge
D2751
Crown - porcelain fused to predominantly base metal*.............................321 + Lab
D2791
Crown - full cast predominantly base metal*..............................................300 + Lab
D2810
Crown - 3/4 cast predominantly base metal* .............................................300 + Lab
D2950
Core buildup, including any pins ..........................................................20% Discount
D6211
Pontic - cast predominantly base metal* ....................................................300 + Lab
D6241
Pontic - porcelain fused to predominately base metal* .............................321 + Lab
D6751
Crown - porcelain fused to predominately base metal* .............................321 + Lab
D6791
Crown - full cast predominantly base metal*..............................................300 + Lab
*Lab charges additional - no discount.
Endodontic Dentistry (Root Canal Treatment)
D3110
Pulp cap-direct (excluding final restoration) ............................................................19
D3120
Pulp cap-indirect (excluding final restoration)..........................................................19
D3220
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal
to the dentinocemental junction and application of medicament ......................... 43
Root Canals
D3310
Root canal therapy - anterior (excluding final restoration) ....................................199
D3320
Root canal therapy - bicuspid (excluding final restoration)...................................236
D3330
Root canal therapy - molar (excluding final restoration) .......................................279
Any Root Canal treatment or retreatment that presents unusual difficulties and circumstances may
have an additional charge. Please discuss all fees with the general dentist prior to treatment.
Oral Surgery
D7110
Extraction, single tooth ............................................................................................ 35
D7210
Surgical removal of erupted tooth requiring elevation of mucoperiostial
flap and removal of bone and/or section of tooth...................................................65
D7220
Removal of impacted tooth - soft tissue .................................................................99
D7230
Removal of impacted tooth - partially bony ..........................................................120
D7240
Removal of impacted tooth - completely bony .....................................................142
D7510
Incision and drainage of abscess - intraoral soft tissue..........................................32
Any tooth that presents unusual difficulties and circumstances may incur an additional charge.
Please discuss all fees with the dentist prior to treatment.
Member’s Services
Member Pays
Prosthodontic Dentistry (Dentures)*
D5110
Complete denture - maxillary* .....................................................................414 + Lab
D5120
Complete denture - mandibular* .................................................................414 + Lab
D5211
Maxillary partial denture - resin base (including any conventional
clasps, rests and teeth)*...............................................................................403 + Lab
D5212
Mandibular partial denture - resin base (including any conventional
clasps, rests and teeth)* ..............................................................................403 + Lab
D5213
Maxillary partial denture - cast metal framework with resin denture
bases (including any conventional clasps, rests and teeth)* .....................403 + Lab
D5214
Mandibular partial denture - cast metal framework with resin denture
bases (including any conventional clasps, rests and teeth)*......................403 + Lab
Prosthetics (dentures) fees are our reduced fees for usual and customary services. Any prosthetic
appliance that requires unusual services may be an additional charge. Discuss all fees with the
general dentist prior to any treatment.
*Lab charges additional - no discount.
Orthodontic Dentistry (Braces by a General Dentist)
D8660
Pre-orthodontic treatment visit...............................................................................120
D9310
Consultation (diagnostic service provided by dentist or physician other
than practitioner providing treatment)........................................................5/10-Ortho
Orthodontic Treatment (braces)
D8080
Comprehensive orthodontic treatment of the adolescent dentition..................2,150
D8090
Comprehensive orthodontic treatment of the adult dentition............................2,350
See 4. Plan Exclusions and Limitations
The above orthodontic charges are our reduced fees for full banded Class I malocclusion cases. Any
orthodontic treatment that requires surgery, headgear, unusual or ancillary services or is extended
because of lack of patient cooperation will have an additional charge. At the orthodontic consultation
appointment, the general dentist will explain the length of treatment, all fees, and the payment
schedule. Orthodontic services are offered on a space and time available basis only and are not
available to any person that is currently in treatment or has had treatment planned by any dentist in
the past 6 months.
Broken or lost appliances will be an additional charge.
Periodontic Dentistry (Gum Disease Treatment)
D4250
Mucogingival surgery - per quadrant.....................................................................350
D4260
Osseous surgery (including flap entry and closure) - per quadrant .....................480
D4341
Periodontal scaling and root planing - per quadrant ..............................................65
D4910
Periodontal maintenance procedures (following active therapy) ............................48
At the diagnostic evaluation appointment, the participating general dentist will explain the
treatment procedure and the fees. The above periodontic charges are our reduced fees for usual and
customary periodontal services. Any periodontal treatment that requires root resection, gingival
grafts, or other services will have an additional charge at a reduced rate. Discuss this with the dentist
prior to beginning treatment.
General
D9110
D9430
D9440
D9999
Palliative (emergency) treatment of dental pain ...................................20% Discount
Office visit for observation (during regularly scheduled hours)...............................12
Office visit - after regularly scheduled hours .......................................................UCR
Broken Appointment within 24 hours.......................................................................25
All of the listed charges are reduced fees for services performed by a participating general
dentist. Fees are subject to change without notice.
Specialty Dentistry
Any treatment provided by a participating specialist, if available, in Endodontics (root canal),
Pediatric Dentistry (children’s dentistry), Prosthodontics (Dentures), Orthodontics (teeth
straightening), Periodontics (gum disease treatment) or Oral Surgery will be charged at a 20%
reduction of participating specialist’s fees for that particular case. Some specialists may require a
consultation visit before treatment is initiated. Discuss each case with the specialist prior to
beginning any treatment.
Any procedure not listed is available on a fee for service basis at a 20% discount.
Consult with your participating general dentist prior to beginning any treatment.
Plan Exclusions and Limitations
1. The following exclusions apply:
A. Services for injuries or conditions that are covered under Workman’s Compensation or
Employer’s Liability Laws;
B. Services, which are provided without cost to the member by any municipality, county or
other political subdivision;
C. Cost of dental care, which is covered under automobile, medical, no fault, or similar type
insurance;
D. General anesthesia (put to sleep), I.V. sedation, Nitrous Oxide, and hospitalization or
hospital or medical charges of any kind; and
E. Osseointegrated implants.
2. Member’s dental fees apply only when treatment is performed at a PARTICIPATING DENTAL
OFFICE. If the services of a non-participating specialist or non-participating general dentist are
required, these dental fees do not apply and the patient will be responsible to the nonparticipating dentist for his usual, customary and reasonable fee.
3. Reduced fees will not be honored if dental treatment is already in progress or if the patient’s
membership is no longer valid.
4. Any member accepted for orthodontic treatment must remain a member of the dental plan for
the full duration of their treatment or risk additional charges from their participating
Orthodontist.
5. A patient's existing dental or medical condition may necessitate extra precautionary
procedures and require additional charges. Please discuss all fees with the dentist prior to
Current Dental Terminology © 2004 American Dental Association. All rights reserved.
some frequently asked questions
about Texas Dental Plans
information regarding
membership
What is a Dental Referral Plan?
Dental Fees
A Dental Referral Plan allows member patients to have their
dental fees GREATLY REDUCED by established dental
professionals in the community. This is not a Dental HMO
plan or dental insurance.
Most dental procedures are listed on the “Member’s Dental
Fees” page. Any procedure not listed is still available at a
discount, per our fee schedule, unless indicated under “Plan
Exclusions and Limitations.” Specialist fees are charged at a
flat reduction as indicated by your fee schedule.
How are dental fees reduced?
TDP participating dentists do not have to complete insurance
paperwork or claim forms, have lower billing costs, less
uncollectible debts, and can afford to discount fees for the
increased volume of patients received through TDP.
Who is eligible?
You and each individual residing in your household may
join. This includes family and non-family members. There are
no age limits.
What if I have Dental Insurance?
Dental insurance will supersede our program and pay
as if TDP did not exist. The member will not benefit by
having two programs, unless TDP is used to reduce fees
for procedures not covered by the dental insurance.
When will membership begin?
Membership becomes effective when you receive your
membership I.D. card. Your card and a Participating Dentist
Directory should arrive within two (2) weeks after TDP
receives your application.
In emergency cases only, membership becomes effective
when the TDP office receives your application and payment.
TDP will verify your membership to the participating Dentist
from whom you receive treatment.
Where are dental services obtained?
TDP members are not required to select a specific primary
dentist. Each member or dependent included under the plan
may see ANY participating dentist, including specialists.
Referrals are not required. To make an appointment, simply
call a participating dental office and tell the receptionist you
are a TDP member. Always present your membership card
prior to any treatment.
Your membership is valid with ANY Texas Dental Plans, Inc.
participating dentist in the state.
To receive reduced dental fees, the member is responsible
for paying all fees directly to the dental office at the time
the dental service is performed or you will be charged
the doctor’s full fees. Failure to do so could terminate
membership.
Dental fees may vary when unusual circumstances and/or
materials are required. Consult with your dentist before
beginning any treatment.
Emergencies
Members are charged the amounts specified on the fee
schedule for dental emergency procedures during regular
office hours. Emergencies, during non-office hours and
weekends, are charged at the dentist’s customary off-hour
emergency rate.
Canceling appointments
If you are unable to keep your scheduled appointment,
notify your dental office at least 24 hours in advance.
Otherwise, you will incur a “broken appointment charge.”
Broken appointments result in wasted time and increased
costs. Please try to keep all appointments.
Grievance procedures
If you have a question concerning dental charges please
consult first with your dentist. Direct any grievances to TDP.
Unresolved grievances will be settled by arbitration.
Call Member Services at 1-800-488-2801.
Group Membership
Special group membership rates are available for groups
of five or more enrolled.
Continuous enrollment
If your employment is terminated, you may still be a Texas
Dental Plans member through the TDP Individual Enrollment
Program. Please contact Texas Dental Plans for assistance.
about CompBenefits
CompBenefits, the dental and vision plan of choice
for more than 5 million members nationwide, offers
a portfolio of affordable products built on 25 years of
service and stability. Since 1978, CompBenefits has
maintained its commitment to meeting others’ needs
with local focus, exceptional customer support and
an unparalleled network of providers. Throughout its
history, CompBenefits has grown to meet customer and
provider expectations and remains committed to its
leadership role in the dental and vision benefits industry.
CompBenefits Family of Companies
CompBenefits
CompBenefits Company
CompBenefits Insurance Company
CompBenefits Dental, Inc.
CompBenefits of Alabama, Inc.
CompBenefits of Georgia, Inc.
American Dental Plan of North Carolina, Inc.
CompBenefits Corporation
Texas Dental Plans
P.O. Box 769729
Roswell, GA 30076
Member Services: 1-800-488-2801
Direct Sales/Dallas: 1-800-275-2584
Direct Sales/Houston: 1-800-679-7883
Direct Sales/San Antonio: 1-800-721-0455
CBOV
what’s new online...
www.mycompbenefits.com
Explore the exciting new features that make it easier for you
to find information and make changes to your CompBenefits
vision and dental plans.
• Change Personal Information: You can now access and change personal demographic
information, such as your name and address, directly from your CompBenefits account.
• Change Your DHMO Dental Provider: To change your DHMO provider,
simply follow the step-by-step instructions on the Member List page and click SAVE.
• Search for a Provider: By registering at MyCompBenefits.com, you can easily search
for a Provider in your area that accepts your specific plan.
• ID Card and Claim Forms: You may print temporary ID Cards and request permanent
ID Cards online. You may also download Claim Forms as needed.
• Print a VisionPass Form: If you need to see an Eye Care Professional, you may need
a VisionPass form. Now you can easily and quickly create and print one online.
• Check the Status of a Claim: It’s easy to check your claim status. Simply select the
family member who received services and enter the time period to obtain a list of claims.
From the list, click on the View option to see details on how the claim was paid.
• Ask Questions about a Claim: We’re here to answer any questions you may have.
From the claims detail screen, click Claims Question. You’ll receive a response within
one business day.
How to Register Online: It’s fast and simple!
Step #1: Go to
www.mycompbenefits.com.
Step #2: Select Click here to Register Now!
Step #3: Type the requested information on the PIN Registration page and click Next.
Step #4: In the next page, enter your Member ID number.
Step #5: Enter your demographic information as it appears on your
enrollment form or as indicated on your ID card. Click Submit.
Member Access to Online Services
24 Hours a Day, 7 Days a Week
Texas Dental Plans, Inc./Group Plan
TDP brings simple, affordable choices.
Texas Dental Plans (TDP) provide the additional security and convenience
you need for the health options your traditional insurance plan may not
cover. Along with comprehensive dental coverage, this TDP plan also
includes vision and hearing benefits at no additional cost. Our special
discount plans offer substantial savings and advantages to our members.
Easy to use! Easy to save!
Because we are not an insurance company or an HMO, our plan
avoids high medical costs, annoying paperwork, and restrictions on
procedures. Simply see the participating provider of your choice and
pay the discounted fee at the time of service. Other advantages to our
plans include no deductibles, no waiting periods, and no pre-existing
condition limitations.
Dedicated professionals.
Currently, we have over 15,000 dental and vision providers in cities
across the country, and the list continues to grow. You are free to choose
from the large panel of providers and may change providers at any time
without notifying our office. There are no limits on the number of visits and
services. Pre-existing conditions are accepted!
dental
• Up to 65% savings on dental services.
• Credentialed dentists in private practice.
• No claim forms or deductibles.
• Orthodontics and cosmetic dentistry included.
• No maximums per year.
The number of conveniently located providers, low cost, and ease
of use makes TDP preferable to other plans of its type. Simply see the
participating dentist of your choice, pay the discounted fee at the time
of treatment, and enjoy up to 65% savings!
All dental services are discounted! After joining TDP, you will receive
a list of dental procedures and discounted prices honored by general
dentists. TDP specialists offer our members a specified discount off the
specialists’ usual and customary rates. Remember, you do not need a
referral to visit any of our specialists.
An affordable
dental plan for you
and your family
from the company
you can trust
Enriched Vision and Hearing Enhancement...
All complimentary with your Dental Enrollment
vision
• Up to 50% savings on eyewear
• No restrictions on frames or lenses
• No pre-approval or claim forms
If you are a member of our dental plan, you can also save money on
vision care with Preferred Vision Care (PVC). PVC is easy to use with
convenient locations nationwide. Simply present your ID card to the
participating location and enjoy the savings. Your membership entitles
you to a large selection of regular glasses, prescription sunglasses,
sport glasses, and special glasses for occupational or recreational
needs. For participating vision locations in your area, call PVC at
1-888-526-8000.
* Please note eye exams are not covered.
hearing
• Free hearing evaluation
• Up to 15% off hearing aid purchases
TDP has made Beltone products available to you at significant savings.
With locations across the United States, Beltone offers a variety of services
from hearing exams and evaluations to more than 70 models of hearing
instruments. To use your discount, simply show your ID card. For the
Beltone Hearing Aid Center nearest you, call 1-800-235-8663.