Member Dental Fees Texas

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Brittany Hines
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Dental Discount Plan Member Dental Fees Texas Member s Services Member Pays Member s Services Member Pays Diagnostic and Preventive Dentistry Prosthodontic Dentistry (Dentures)* D0120 Periodic oral

1 Dental Discount Plan Member Dental Fees Texas Member s Services Member Pays Member s Services Member Pays Diagnostic and Preventive Dentistry Prosthodontic Dentistry (Dentures)* D0120 Periodic oral evaluation...15 D5110 Complete denture - maxillary* Lab D0150 Comprehensive oral evaluation...15 D5120 Complete denture - mandibular* Lab D0210 Intraoral - complete series (including bitewings)...30 D5211 Maxillary partial denture - resin base (including any conventional D0220 Intraoral - periapical - first film...5 clasps, rests and teeth)* Lab D0230 Intraoral - periapical each additional film...4 D5212 Mandibular partial denture - resin base (including any conventional D0270 Bitewing - single film...5 clasps, rests and teeth)* Lab D0330 Panoramic film D5213 Maxillary partial denture - cast metal framework with resin denture D0460 Pulp vitality tests bases (including any conventional clasps, rests and teeth)* Lab D0470 Diagnostic casts D5214 Mandibular partial denture - cast metal framework with resin denture D1110 Prophylaxis - adult bases (including any conventional clasps, rests and teeth)* Lab D1120 Prophylaxis - child Prosthetics (dentures) fees are our reduced fees for usual and customary services. Any prosthetic D1351 Sealant - per tooth...20% Discount appliance that requires unusual services may be an additional charge. Discuss all fees with the (Patients who have not had regular cleanings may require gum treatment) general dentist prior to any treatment. *Lab charges additional - no discount. D4355 Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis...45 Orthodontic Dentistry (Braces by a General Dentist) D9310 Consultation (diagnostic service provided by dentist or physician other D8660 Pre-orthodontic treatment visit than practitioner providing treatment)...15/10-ortho D9310 Consultation (diagnostic service provided by dentist or physician other D9999 Infection control fee... 9 than practitioner providing treatment)...5/10-ortho **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. Orthodontic Treatment (braces) D8080 Comprehensive orthodontic treatment of the adolescent dentition...2,150 Cosmetic and Restorative Dentistry D8090 Comprehensive orthodontic treatment of the adult dentition...2,350 Permanent and Baby Teeth See 4. Plan Exclusions and Limitations Amalgam Restorations (Silver Fillings) 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 D2110 Amalgam - one surface, primary...34 because of lack of patient cooperation will have an additional charge. At the orthodontic consultation D2120 Amalgam - two surfaces, primary...44 appointment, the general dentist will explain the length of treatment, all fees, and the payment D2130 Amalgam - three surfaces, primary...54 schedule. Orthodontic services are offered on a space and time available basis only and are not D2140 Amalgam - one surface, permanent...34 available to any person that is currently in treatment or has had treatment planned by any dentist in D2150 Amalgam - two surfaces, permanent...44 the past 6 months. D2160 Amalgam - three surfaces, permanent...54 Broken or lost appliances will be an additional charge. Resin Fillings (Tooth Colored) D2330 Resin - based composite - one surface, anterior...34 Periodontic Dentistry (Gum Disease Treatment) D4250 Mucogingival surgery - per quadrant 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* Lab D2791 Crown - full cast predominantly base metal* Lab D2810 Crown - 3/4 cast predominantly base metal* Lab D2950 Core buildup, including any pins...20% Discount D6211 Pontic - cast predominantly base metal* Lab D6241 Pontic - porcelain fused to predominately base metal* Lab D6751 Crown - porcelain fused to predominately base metal* Lab D6791 Crown - full cast predominantly base metal* 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 Root Canals D3310 Root canal therapy - anterior (excluding final restoration) D3320 Root canal therapy - bicuspid (excluding final restoration) D3330 Root canal therapy - molar (excluding final restoration) 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 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 D7240 Removal of impacted tooth - completely bony 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. D4260 Osseous surgery (including flap entry and closure) - per quadrant 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.

2 some frequently asked questions about Texas Dental Plans What is a Dental Referral Plan? 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. 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. information regarding membership Dental Fees 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. 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 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.

3 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. 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.

4 what s new online... 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 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

5 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. An affordable dental plan for you and your family from the company you can trust 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.

6 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 * 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

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www.bcbsla.com 23XX2293 R3/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company 1 Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are