|
The following fees apply
to General Dentists and Orthodontists. Any specialist
(Oral Surgeon, Periodontist, Pediatric Dentist, etc.)
will charge a "member pay" fee equal to his
regular fee minus 20%.
| Member
Services |
Member
Pays
|
| D0120 |
Periodic
Oral Evaluation |
$20 |
| D0140 |
Limited
Oral Evaluation (Emergency Exam) |
22 |
| D0210 |
Complete
Series X-ray |
41 |
| D0220 |
Single
Peri-apical X-ray |
5 |
| D0230 |
Each
Additional PA Film |
5 |
| D0272 |
Bitewings
- Two Films |
11 |
| D0330 |
Panoramic
X-ray |
42 |
| D0470 |
Study
Models |
17 |
| D1110 |
Prophylaxis-Adult
(Teeth Cleaning) |
30 |
| D1120 |
Prophylaxis-Child
(Teeth Cleaning) |
25 |
| D1203 |
Fluoride
Treatment |
8 |
| D1351 |
Sealant
(per tooth) |
17 |
| D1510 |
Space
Maintainer-Fixed Unilateral |
125 |
| D1515 |
Space
Maintainer-Fixed Bilateral |
150 |
| D9999 |
Disposables |
5 |
| D9972 |
Cosmetic
Bleaching (per arch) |
165 |
| Restorative
Dentistry |
Member
Pays
|
|
Amalgam
Restorations Silver Fillings for Posterior (back)
Teeth |
|
| D2140 |
Cavities
involving one surface |
$38 |
| D2150 |
Cavities
involving two surfaces |
49 |
| D2160 |
Cavities
involving three surfaces |
60 |
|
Composite
Fillings (Tooth Colored) For Anterior (Front)
Teeth |
|
| D2330
|
Cavities
involving one surface |
50 |
| D2331
|
Cavities
involving two surface |
63 |
| D2332 |
Cavities
involving three surface |
86 |
| D2335
|
Composite
Resin (involving incisal) |
86 |
|
Composite
Fillings (Tooth Colored) For Posterior (Back)
Teeth |
|
| D2385 |
Cavities
involving one surface |
60 |
| D2386 |
Cavities
involving two surface |
73 |
| D2387 |
Cavities
involving three surface |
95 |
| Crown
and Bridge Base Fees |
Member
Pays
|
| D2740 |
Crown-
Porcelain |
$600 |
| D2750 |
Crown- Porcelain fused to high noble metal |
530+Metal |
| D2752 |
Crown- Porcelain fused to noble metal |
530+Metal |
| D2790 |
Crown-
Full cast high noble metal |
530+Metal |
| D2792 |
Crown-
Full cast noble metal |
530+Metal |
| D2782 |
Crown-
3/4 cast noble metal |
450+Metal |
| D2780 |
Crown-
3/4 cast high noble metal |
450+Metal |
| D2931 |
Prefabricated
stainless steel crown |
96 |
| D2940 |
Sedative
Filling |
22 |
| D2950 |
Core
build up (including any pins) |
75 |
| D2951 |
Pin
retention (per tooth, in addition to restoration) |
15 |
| D2954 |
Prefabricated
post and core in addition to crown |
88 |
| Endodontics
(Root Canal Treatment) |
Member
Pays
|
|
Diagnostic
Exam |
20%
Off U&C* |
| D3110 |
Pulp
Cap- Direct (excluding final restorations) |
20%
Off U&C* |
| D3220 |
Therapeutic
Pulpotomy (excluding final restorations) |
20%
Off U&C* |
|
Root
Canals |
|
| D3310 |
Anterior
(excluding final restoration) |
20%
Off U&C* |
| D3320 |
Bicuspid
(excluding final restoration) |
20%
Off U&C* |
| D3330 |
Molar
(excluding final restoration) |
20%
Off U&C* |
| D3340 |
Molar
(excluding final restoration) |
20%
Off U&C* |
| Oral
Surgery |
Member
Pays
|
| Extractions
(Include local anesthesia, suturing, if needed,
and routine postoperative care) |
| D7110 |
Routine
Extraction (Single Tooth) |
20%
Off U&C* |
| D7210 |
Surgical
Extraction |
20%
Off U&C* |
| D7220 |
Removal
of Impacted Tooth- Soft Tissue |
20%
Off U&C* |
| D7230 |
Removal
of Impacted Tooth- Partially Bony |
20%
Off U&C* |
| D7240 |
Removal
of Impacted Tooth- Completely Bony |
20%
Off U&C* |
| D7510 |
Incision
and Drainage of Abcess- Intraoral soft tissue |
20%
Off U&C* |
| Prosthetics
(Dentures) |
Member
Pays
|
| D5110 |
Complete
Maxillary (Upper Denture) Excluding Extractions |
$550 |
| D5120 |
Complete
Mandibular (Lower Denture) Excluding Extractions |
550 |
| D5211 |
Upper
Partial Denture- Resin Base
(including any conventional clasps and rests) |
395 |
| D5212 |
Lower
Partial Denture- Resin Base
(including any conventional clasps and rests) |
395 |
| D5213 |
Upper
Partial Denture- cast metal framework w/ resin
denture bases (including any conventional clasps
and rests) |
610 |
| D5214 |
Lower
Partial Denture- cast metal framework w/ resin
denture bases (including any conventional clasps
and rests) |
610 |
| D5710 |
Rebase
- Complete Upper Denture |
183 |
| D5711 |
Rebase
- Complete Lower Denture |
183 |
| D5730 |
Reline
Complete Upper Denture Chairside |
97 |
| D5731 |
Reline
Complete Lower Denture Chairside |
97 |
|
Fixed
Partial Denture Retainers-Crowns |
|
| 06750
|
Fixed
Bridge Per Unit-Porcelain fused to high noble
metal |
430 |
| 06751 |
Fixed
Bridge Per Unit-Porcelain fused to predominantly
base metal |
430 |
| (any
prosthetic appliance that requires unusual services
might be an additional charge. Discuss this
with your patient prior to treatment.) |
| Periodontics |
Member
Pays |
| D4421 |
Gingivectomy
or Gingivoplasty - per quadrant |
20%
Off U&C* |
| D4341 |
Periodontal
Scaling and Root Planing - per quadrant |
20%
Off U&C* |
| D4910 |
Periodontal
Prophylaxis |
20%
Off U&C* |
| Orthodontics |
Member
Pays
|
| Initial
Exam |
No
Charge |
Orthodontic
Treatment (all ages)
|
| Class
1 Treatment |
$3,250 |
| Class
2 Treatment |
3,450 |
| Class
3 Treatment |
3,650 |
| (Includes
placement of appliance, treatment for two years
(24 months), removal of appliances, records
and placement of retainer. Does not include
the cost of the retainer to be paid by IDP member.
The Orthodontist will explain the length of
treatment, all fees and the payment schedule.
Orthodontic discount is not available to any
member currently in treatment. Orthodontic treatment
that requires surgery or unusual services may
require an additional charge. Discuss this with
the Orthodontist prior to beginning treatment). |
In the event that Providers Usual and
Customary charge is equal to or less than the member
pay amount,or if the procedure is not listed on the
IDP Member Fee Schedule, Provider agrees to discount
his Usual and Customary fee by a minimum of twenty percent
(20%). In emergency situations, whereby Provider sees
a IDP patient after hours or enters exnary circumstances,
an additional fee of up to ten percent (10%) of the
IDP scheduled fees may be added to Patient's billed
charges.
| Limitations
and Exclusions |
| 1. Any treatment
which in the opinion of the attending dentist is not necessary for the
patient's dental health or that cannot be performed because of the general
health of the patient. |
| 2. Treatment
for injuries or conditions that are covered under Workman's Compensation
or Employees Liability Laws, Automobile, Medical, No Fault or similar
types insurance. Services which are provided without cost to the patient
by any County, Municipality or other political subdivision. |
| 3. Member Benefits
and Dental Fees Schedule apply only when treatment is performed at a
participating dental office. If the service of a non-participating dentist
is required, or services are performed in a hospital facility, these
dental fees do not apply and the patient will be responsible to the
nonparticpating dentist or hospital for the usual fees. |
| 4. Any dental
treatment already in progress will be excluded. Special arrangements
may be made at the option of participating providers to assume treatment
in progress. Fees for assumption of treatment should be negotiated by
provider and member. These fees may or may not be relative to Indiana
Dental Plan, Inc. Member Fees Schedule. |
| 5. When the member's
Membership is no longer valid. |
| 6. The members
may select the dentist of their choice; however, if the dentist selected
is not a participating dentist, the fees charged by the nonparticpating
dentist must be paid by the member. Any licensed dentist is eligible
to participate in the plan. Application to become a plan provider may
be obtained from the Indiana Dental Plan, Inc. office. A providers
participation will be contingent on acceptance and notification by Indiana
Dental Plan, Inc. |
| 7. Fees listed
on the Members Benefits and Dental Fees Schedule are for procedures
done by participating general dentists and orthodontists and should
be considered specialist's fees. |
| 8. Participating
specialists, other than an orthodontist, charge
a "member pay" fee equal to his regular
fee minus 20%. |
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