11aetnaDMO_BPS - Fairfax County Public Schools Member...

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CODE PATIENT PAYS CODE PATIENT PAYS D0120-D0180 No Charge D0277 No Charge D0210 No Charge D0330 No Charge D0220-D0230 No Charge D0460 No Charge D0240 No Charge D0470 No Charge D0250-D0260 No Charge D0472-D0474 No Charge D0270-D0274 No Charge D1110 No Charge D1510 No Charge D1120 No Charge D1515 No Charge D1203 No Charge D1520 No Charge D1206 No Charge D1525 No Charge D1330 No Charge D1550 $12 D1351 No Charge D1555 $12 D2140 No Charge D2390 $40 D2150 No Charge D2391 No Charge D2160 No Charge D2392 No Charge D2161 No Charge D2393 No Charge D2330 No Charge D2394 No Charge D2331 No Charge D2940 No Charge D2332 No Charge D2951 $6 D2335 No Charge D2510 $160 D6073 $185 D2520 $160 D6074 $185 D2530 $160 D6075 $185 D2542 $160 D6076 $185 D2543 $160 D6077 $185 D2544 $160 D6078 $250 D2610 $160 D6079 $250 D2620 $160 D6094 $185 D2630 $160 D6205 $185 D2642 $160 D6210 $185 D2643 $160 D6211 $185 D2644 $160 D6212 $185 D2650 $160 D6214 $185 D2651 $160 D6240 $185 D2652 $160 D6241 $185 D2662 $160 D6242 $185 Implant/Abutment Supported Fixed Denture for Partially Edentulous Arch Abutment Supported Crown - (Titanium) Pontic - Porcelain Fused to High Noble Metal Inlay, Composite/Resin - 3 Surf Implant Supported Retainer for Ceramic FPD Implant Supported Retainer for Porcelain Fused to Metal FPD (Titanium, Titanium Alloy or High Noble Metal) Implant Supported Retainer for Cast Metal FPD (Titanium, Titanium Alloy or High Noble Metal) Implant/Abutment Supported Fixed Denture for Completely Edentulous Arch Inlay, Porcelain/Ceramic - 3 or More Surf Onlay, Porcelain/Ceramic - 4 or More Surf Onlay, Porcelain/Ceramic - 2 Surf Inlay, Composite/Resin - 1 Surf Onlay, Porcelain/Ceramic - 3 Surf Inlay, Composite/Resin - 2 Surf Amalgam - 3 Surf Primary or Permanent Inlay, Porcelain/Ceramic - 2 Surf CROWNS/BRIDGES Inlay - Metallic 1 Surf Onlay - Metallic 2 Surf Onlay, Metallic - 4 or More Surf Inlay, Porcelain/Ceramic - 1 Surf Abutment Supported Retainer for Cast Metal FPD (Noble Metal) Inlay - Metallic 2 Surf Resin-Based Composite 2 Surf, Anterior Application of Topical Fluoride Varnish Onlay - Metallic 3 Surf Resin-Based Composite 2 Surf, Posterior Resin-Based Composite 3 Surf, Posterior Resin-Based Composite 4+ Surf, Posterior Sedative Filling Pin Retention - In Addition to Restoration Inlay - Metallic 3 Surf Space Maintainer - Removable Bilateral Space Maintainer - Removable Unilateral Space Maintainer - Fixed Unilateral Space Maintainer - Fixed Bilateral Resin-Based Composite 1 Surf, Anterior Oral Hygiene Instruction Amalgam - 4+ Surf Primary or Permanent Diagnostic and Preventive services may be subject to age and frequency limitations. See your booklet for details. Resin-Based Composite Crown, Anterior Resin-Based Composite 1 Surf, Posterior Sealant - Per tooth Bitewings Oral Evaluations Fluoride - Child Prophy - Adult Prophy - Child PREVENTIVE Vertical Bitewings - 7 to 8 Films Panoramic X-Ray Full mouth series X-rays Fairfax County Public Schools 2011 DMO Benefits Summary Effective Date: 01-01-2011
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This note was uploaded on 01/23/2012 for the course PSY 031:001:AA taught by Professor Shaunpvecera during the Spring '08 term at University of Iowa.

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11aetnaDMO_BPS - Fairfax County Public Schools Member...

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