Care Improvement Plus Dental Benefits - MD
BASIC BENEFIT - 2012 (CIP Gold Members Only):
| CDT | ADA Service Descriptions | Basic In-Network | Limitations |
|---|---|---|---|
| Per Office Visit Co-pay | $10 | ||
| D0120 | PERIODIC ORAL EVALUATION | Covered in Full | 1 per yr either D0120 or D0150 (1 every 3 yrs) |
| D0150 | COMPREHENSIVE ORAL EVALUATION | Covered in Full | |
| D0272 | BITEWINGS-2 FILMS | Covered in Full | 1 per year either D0272 or D0274 |
| D0274 | BITEWINGS-4 FILMS | Covered in Full | |
| D1110 | PROPHYLAXIS-ADULT | Covered in Full | 1 per year |
| D5410 | ADJUSTMENT COMPLETE DENTURE-MAXILLARY | Covered in Full | 2 per year of any of the 4 D5410 - D5422 |
| D5411 | ADJUSTMENT COMPLETE DENTURE-MANDIBULAR | Covered in Full | |
| D5421 | ADJUSTMENT PARTIAL DENTURE-MAXILLARY | Covered in Full | |
| D5422 | ADJUSTMENT PARTIAL DENTURE-MANDIBULAR | Covered in Full | |
| D2140 | AMALGAM-1 SURFACE PERMANENT | Discount 20% UCR | Unlimited |
| D2150 | AMALGAM-2 SURFACES PERMANENT | ||
| D2160 | AMALGAM-3 SURFACES PERMANENT | ||
| D2161 | AMALGAM-4/MORE SURFACES PERMANENT | ||
| D2330 | RESIN-BASED COMPOSITE-1 SURFACE ANTERIOR | ||
| D2331 | RESIN-BASED COMPOSITE-2 SURFACES ANTERIOR | ||
| D2332 | RESIN-BASED COMPOSITE-3 SURFACES ANTERIOR | ||
| D2335 | RESIN-BASED COMPOSITE-4/MORE SURF-INCISAL ANGLE | ||
| D2391 | RESIN-BASED COMPOSITE - 1 SURFACE, POSTERIOR | ||
| D2392 | RESIN-BASED COMPOSITE - 2 SURFACES, POSTERIOR | ||
| D2393 | RESIN-BASED COMPOSITE - 3 SURFACES, POSTERIOR | ||
| D2394 | RESIN-BASED COMPOSITE - 4 OR MORE SURFACES, POSTERIOR | ||
| D4341 | PERIODONTAL SCALING & ROOT PLANING PER QUADRANT | Discount 20% UCR | Unlimited |
| D4342 | PERIODONTAL SCALING AND ROOT PLANING - 1-3 TEETH, PER QD | ||
| D5110 | COMPLETE DENTURE - MAXILLARY | Discount 20% UCR | 2 Dental Plates- either full or partial, or any combination thereof, once every 3 years |
| D5120 | COMPLETE DENTURE - MANDIBULAR | ||
| D5211 | MAXILLARY PARTIAL DENTURE - RESIN BASE | ||
| D5212 | MANDIBULAR PARTIAL DENTURE - RESIN BASE |
PLEASE NOTE: MEMBERS ON THE BASIC PLAN HAVE A $10 OFFICE VISIT CO-PAY. MEDICARE ADVANTAGE MEMBERS CANNOT BE BALANCE BILLED FOR COVERED SERVICES.