Become an Avesis Provider

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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.