+ All Categories
Home > Documents > Presbyterian Medicare Advantage Plans · 2790 Crown full cast high nbl mtl $582 $249 2791 Crown...

Presbyterian Medicare Advantage Plans · 2790 Crown full cast high nbl mtl $582 $249 2791 Crown...

Date post: 03-Jun-2020
Category:
Upload: others
View: 2 times
Download: 0 times
Share this document with a friend
7
*Medicare has neither reviewed nor endorsed this information Presbyterian Medicare Advantage Plans Buy-up Dental Option Elite Dental Plan
Transcript
Page 1: Presbyterian Medicare Advantage Plans · 2790 Crown full cast high nbl mtl $582 $249 2791 Crown full cast predom base mtl $480 $206 2792 Crown full cast noble metal $515 $221 2794

*Medicare has neither reviewed nor endorsed this information

Presbyterian Medicare Advantage PlansBuy-up Dental Option

Elite Dental Plan

Page 2: Presbyterian Medicare Advantage Plans · 2790 Crown full cast high nbl mtl $582 $249 2791 Crown full cast predom base mtl $480 $206 2792 Crown full cast noble metal $515 $221 2794

Elite Dental Plan Something else to smile aboutBenefitSource and Presbyterian Medicare Advantage have partnered to offer this PPO dental plan.

The Elite Dental Plan is a PPO dental plan specifically designed for Presbyterian Medicare Advantage Plan members.

As a PPO dental plan, the Elite Plan provides greater savings when obtaining care from PPO Dental Providers but still has coverage when going out-of-network for dental care.

Advantage of the Elite Dental Plan • Freedom to see any licensed Provider• Low monthly premium of $35.35 per person • No deductible for in-network dentists for preventive

and diagnostic care• Low, $50 annual deductible applies to in-network

dental care for all other dental procedures.• $75 annual deductible for out-of-network dental care • Out-of-pocket costs limited to guaranteed pre-set

fee schedule for in-network services• 6 month waiting period for major (class III)* services• $1,000 annual maximum per person• Over 2,000 PPO Dental providers throughout New Mexico

Plan benefits:When using participating PPO Dental Providers, you pay the listed in-network PPO fee directly to the dental office at the time of service. If you obtain dental services from non-participating dental providers (out-of-network), the plan pays the amount listed, but the dental office may balance bill you for any differences in fees.

This plan is underwritten and administered by Companion Life Insurance Company, an A.M. Best rating A+ (Superior) rated company.

Rating as of January 25, 2019. For latest rating; access www.ambest.com. The rating represents an independent opinion from the

leading provider of insurer ratings of a company’s financial strength and ability to met its obligations to policyholders.

* Major (class III) services include: fixed prosthodontics, endodontics, periodontics, removable prosthodontics, and oral surgery.

PHPMA20

Page 3: Presbyterian Medicare Advantage Plans · 2790 Crown full cast high nbl mtl $582 $249 2791 Crown full cast predom base mtl $480 $206 2792 Crown full cast noble metal $515 $221 2794

How to Join How do I join the Elite Dental Plan? Review the entire brochure, complete and sign the attached

Enrollment/Authorization Form. Return your Enrollment/

Authorization Form with payment for the appropriate amount

to BenefitSource.

Payment OptionsANNUAL PAYMENT • Annual payment is only available for those enrolling January 1.

Enrollment forms must be mailed by December 18th to begin

coverage January 1.

MONTHLY BANK DRAFT• Enrollment forms mailed by the 18th of any month become effective

the first day of the following month. Enrollment on the Elite Dental

Plan is allowed throughout the year.

• Payment can be made by Monthly Electronic Fund Transfer.

To initiate the Monthly Bank Draft option, complete the attached

Enrollment/Authorization Form and provide a check made out

to BenefitSource for the 1st month’s payment. In addition, please

include a voided check from the bank you wish to have the

membership fees drafted. Each month your premium will be

automatically drafted from your bank account between the 3rd and

5th of the month for the next month’s coverage. No monthly checks,

no postage, no statements. The Monthly Bank Draft option is reliable

and automatic!

• BenefitSource will make reasonable efforts to collect unpaid

premiums by sending written notice after the date that delinquent

charges are due. Failure to pay any delinquent premiums will result

in termination of coverage. The 12 month benefit period is continuous

and therefore does not allow for any lapse in coverage.

• Any additional charges to your account due to insufficient funds or

overdraft fees will be the members responsibility and will not

be refunded by BenefitSource.

Limitations and Exclusions• Treatment for cosmetic purposes or medically necessary procedures

are not covered benefits.

• Education, counseling, or training including supplies for nutrition,

dental hygiene, or harmful habits are not covered benefits.

• Pre-existing conditions: Placement of prosthesis due to a tooth

missing prior to an insured’s enrollment is not covered..

• Services must be performed by a licensed Provider.

• Major services have a five-year replacement period.

• Please refer to your certificate of coverage for a complete list of

limitations and exclusions.

Termination of Coverage

• If you would like to cancel your coverage, you must submit a

written cancellation request. If you cancel your membership as a

Presbyterian Medicare Advantage Plan member and you want to

terminate your dental coverage, you must also notify BenefitSource

in writing. All written cancellation requests received by the 23rd of the

month will become effective the first day of the following month.

Any cancellation requests received after the 23rd will take effect

on the 1st of the 2nd following month. Any Bank Draft member who

elects to terminate their dental coverage will not be refunded any

drafted premium.

• This plan automatically renews, unless it is terminated by the

member, or by BenefitSource for non-payment of premium.

• Any Plan members who terminate their dental plan coverage

mid-year will be permanently restricted from re-enrolling in this plan.

For more information, please contact us at: 1804 Juan Tabo NE, Suite A, Albuquerque, NM 87112

888 862 8659 | 505 237 1501 | BenefitSource.org

Visit BenefitSource.org or call 888.862.8659 or 505.237.1501 for a current list of providers and complete fee schedule.

Page 4: Presbyterian Medicare Advantage Plans · 2790 Crown full cast high nbl mtl $582 $249 2791 Crown full cast predom base mtl $480 $206 2792 Crown full cast noble metal $515 $221 2794

Elite Dental Plan – Enrollment FormBenefitSource Elite Plan Only Enrollment Authorization Form

Social Security Number Last Name First Name

Date of Birth Sex Home Telephone Alternate Telephone

Home Address City State Zip

Email Address Effective Date

Payment Option for the Elite Plan must be selected.

PAYMENT CHOICE: Please check one. Please make checks payable to BenefitSource, Inc. (For January 1 enrollment only.)

Annual Payment ($424.20) Check Visa MasterCard Discover

Credit Card # Exp. Date CVV#

I have enclosed my Annual Payment of $424.20.

I hereby authorize the release of my dental records to BenefitSource, Inc. for use in quality review program.

Member’s Signature X Date

Monthly Bank Draft ($35.35) Please charge my bank account monthly. Checking Savings

Routing # Account #

I have enclosed a check for my first month’s payment of $35.35 and a voided check.

Draft Authorization / BenefitSource, Inc. Member Agreement Unless I have elected annual payment, I hereby authorize BenefitSource to charge my bank account each month th applicable membership fee to be credited to my account with BenefitSource. This authority is to remain in full force and effect until I notify BenefitSource in writing of it’s termination following my 12 month contract. (My bank is authorized to make corrections should any be necessary). I have read and understand the terms and conditions of the authorization. I hereby authorize the release of my dental records to BenefitSource, Inc. for use in quality review program.

I have read and understand the pre-existing condition limitations and exclusions described in this plan.

Member’s Signature X Date

INTERNAL USE ONLY PSENIOR ELITE

Post Date

Effective Date

Payment Ref

BenefitSource | 1804 Juan Tabo NE, Suite A, Albuquerque, NM 87112 | 888 862 8659 | 505 237 1501 | BenefitSource.org

Page 5: Presbyterian Medicare Advantage Plans · 2790 Crown full cast high nbl mtl $582 $249 2791 Crown full cast predom base mtl $480 $206 2792 Crown full cast noble metal $515 $221 2794

Elite Dental PlanSchedule of Benefits

DIAGNOSTIC 0120 Periodic oral evaluation $0 $33 0140 Limited oral evaluation $0 $50 0145 Oral eval for pt under 3 yrs $0 $33 0150 Comprehensive oral eval $0 $50 0160 Detailed and ext. oral eval prob $0 $71 0170 Re-eval limited problem foc $0 $42 0171 Re-evaluation post op $0 $47 0180 Comprehensive perio eval $0 $56 0210 Intraoral comp series includ btwng $15 $62 0220 Intraoral periapical first film $0 $20 0230 Intraoral periapical each add film $0 $17 0240 Intraoral occlusal film $0 $22 0250 Extra-oral 2D projec radio image $0 $22 0270 Bitewing single film $0 $16 0272 Bitewings two films $0 $31 0273 Bitewings three films $0 $33 0274 Bitewings four films $0 $41 0277 Vertical bitewings 7-8 films $0 $52 0330 Panoramic $17 $53 0340 2D cephalometric radiographic image $0 $72 0470 Diagnostic casts $0 $61 0472 Accession of tissue exam & prep $0 $188 0473 Accession of tissue micro exam $0 $109 0474 Access of tiss micro ex surical marg $0 $109

PREVENTIVE 1110 Prophylaxis adult (cleaning) $13 $58 1120 Prophylaxis child (cleaning) $8 $40 1206 Topical fluoride varnish $0 $24 1208 Topical appl of fluoride $0 $25 1510 Space maintainer-fixed unilateral $0 $157 1515 Space maintainer-fixed bilateral $0 $291 1516 Space maintainer-fixed bilat max $0 $298 1517 Space maintainer fixed bilat mand $0 $298 1520 Space maintainer-remov unilat $0 $201 1525 Space maintainer-remov bilat $0 $270 1526 Space maint bilat maxillary $0 $298 1527 Space maintainer removable bilat mand $0 $278 1550 Re-cement or re-bond space maint $0 $38 1553 Re-Cement/Rebond unilat space main max $0 $34 1555 Removal of fixed space maintainer $0 $39

RESTORATIVE 2140 Amalgam 1 surface prim/perm $36 $54 2150 Amalgam 2 surfaces prim/perm $44 $67 2160 Amalgam 3 surfaces prim/perm $55 $83 2161 Amalgam 4/more surf prim/perm $68 $102 2330 Resin 1 surface -anterior $40 $60 2331 Resin 2 surfaces-anterior $50 $74 2332 Resin 3 surfaces-anterior $61 $92 2335 Resin 4/more surf inclu inc agl $73 $109 2390 Resin based comp crown, ant $87 $131 2391 Resin 1 surface post $47 $70 2392 Resin 2 surfaces post $65 $97 2393 Resin 3 surfaces post $79 $118 2394 Resin 4/more surf post $92 $139

2410 Gold foil- one surface $164 $247 2420 Gold foil-two surfaces $180 $270 2430 Gold foil-three surfaces $181 $271

FIXED PROSTHODONTICS 2510 Inlay metallic 1surface $364 $156 2520 Inlay metallic 2 surfaces $395 $169 2530 Inlay metallic 3 surfaces $443 $190 2542 Onlay metallic 2 surfaces $491 $210 2543 Onlay metallic 3 surfaces $532 $228 2544 Onlay metallic 4 or more surf $531 $227 2610 Inlay porcelain/ceramic 1 sur $434 $186 2620 Inlay porcelain/ceramic 2 surf $339 $145 2630 Inlay porcelain/ceramic 3 surf $447 $192 2642 Onlay porcelain/ceramic 2 surf $494 $212 2643 Onlay porcelain/ceramic 3 surf $581 $249 2644 Onlay porcelain/ceramic 4/more $605 $259 2722 Crown resin with noble metal $517 $221 2740 Crown porcelain ceramic subst $582 $249 2750 Crown porc fused high nbl mtl $572 $245 2751 Crown porc fused to predom base mtl $494 $212 2752 Crown porc fused to nbl mtl $547 $235 2753 Crown proc fused to titanium/alloys $515 $221 2780 3/4 cast high noble metal $554 $237 2781 Crown - 3/4 cast predom base mtl $467 $200 2782 Crown - 3/4 cast nbl mtl $467 $200 2783 Crown - 3/4 porcelain/ceramic $533 $228 2790 Crown full cast high nbl mtl $582 $249 2791 Crown full cast predom base mtl $480 $206 2792 Crown full cast noble metal $515 $221 2794 Crown-titanium $566 $243 2799 Provisional crown- further tx req final $180 $77 2910 Recement/re-bond inlay, only, veneer/part $39 $17 2915 Recemt/Rebnd indir fab/prefab pst & core $43 $19 2920 Recement or rebond crown $46 $20 2921 Reattach of tth frag incisal edge/cusp $127 $55 2929 Prefab porc/ceram prim tooth $125 $54 2930 Prefab stainless steel crown primary $131 $56 2931 Prefab stainless steel crown perm $150 $64 2932 Prefabricated resin crown $146 $62 2933 Prefab stainless steel crown resin $143 $61 2934 Prefab esth ct stain stl crown/prim tth $128 $55 2950 Core build including any pins $113 $49 2951 Pin reten per tooth in add to restor $19 $8 2952 Cast post and core in add to crown $169 $73 2954 Prefab post & core in add to crown $162 $69 2955 Post removal $155 $67 2957 Each add prefab post same tth $28 $12 2960 Labial veneer (resin lam) chair $218 $93 2961 Labial veneer (resin lam) lab $327 $140 2962 Labial veneer (porcelain lam) lab $542 $232 2971 Add pro const new crwn undr exist part $50 $22 2975 Coping $254 $109 2980 Repair crown necss by restor fail $92 $39 2981 Inlay repair neccess by restor fail $90 $38 2982 Onlay repair neccess by restor fail $90 $38 2983 Veneer repair necess by restor fail $90 $38

ENDODONTICS 3110 Pulp cap direct (exclu final restor) $35 $15 3120 Pulp cap indirect (exclu final restor) $35 $15 3320 Endo therapy, premo tth (exclu final resto) $76 $33 3221 Pulpal debride prim/perm. $71 $30 3222 Part pulp for apexogen-Perm tth w incom rt $74 $32 3230 Pulpal therapy anterior primary tooth $125 $54 3240 Pulpal therapy post prim tth $141 $61 3310 Root canal anterior (exclud final restor) $302 $130 3320 Root canal bicus (exclud final restor) $371 $159 3330 Endo therapy, molar tth (exclud final restor) $498 $214 3331 TX of root canal obstruction $260 $111 3332 Incomplete endo therapy $197 $84 3333 Internal root repair of perfo defect $337 $145 3346 Retx of prev root canal therapy - ant $431 $185 3347 Retx of prev root canal therapy -premo $486 $208 3348 Retx of prev root canal therapy molar $613 $263 3351 Apexification/recalcification - initial $184 $79 3352 Apexification/recal - interim $92 $40 3353 Apexificiation/recal - final $307 $131 3410 Apicoectomy/periradi surgery - ant $369 $158 3421 Apicoectomy - premolar (first root) $405 $174 3425 Apicoectomy - molar (first root) $464 $199 3426 Apicoectomy - each add root $135 $58 3430 Retrograde filling- per root $122 $52 3450 Root amputation-per root $218 $93 3460 Endodontic endosseous $1,078 $462 3470 Intentional reimplantation $415 $178 3910 Surg pro for iso of tth with rubber dam $98 $42 3920 Hemisection incl root remov-excl rt can $196 $84

PERIODONTICS 4210 Gingivoplasty/gingivectomy 4/more $265 $113 4211 Gingivopl/gingive 1 to 3 teeth per qd $167 $72 4212 Gingive/gingivopl allow access restor pro $167 $72 4230 Anatomical crown exposure-4/more $519 $223 4231 Anatomical crn expos-1-3 per quad $300 $128 4240 Gingival flap includ root plan 4/more $312 $134 4241 Gingi flap includ root plan 1 to 3 per qd $193 $83 4245 Apically positioned flap $415 $178 4249 Clinical crown length, hard tissue $381 $163 4260 Osseous surg elev full thk flp+clos 4 $554 $237 4261 Osseous surg elev thik flap & clos 1-3 per qd $328 $140 4263 Bone replace graft retain ntrl tth- first $244 $104 4264 Bone replace graft retain ntrl tth-add’l in qd $208 $89 4265 Biolog mat to aid soft/osseous tiss regen $229 $98 4266 Guided tiss regen - resorb barrier pr site $448 $192 4267 Guided tiss regen-nonrestor bar pr site $283 $121 4268 Surgical revision procedure per tth $419 $179 4270 Pedicle soft tissue graft proc $318 $136 4273 Autogen connec tissue graft proc first $476 $204 4274 Mesial/distal wedge pro,single tth $325 $139 4275 Nonautogen conn tissue graft $435 $186 4276 Combined conn tissue & dble ped graft $533 $228 4277 Free soft tissue graft proc first $433 $186 4278 Free soft tissue graft procedure $216 $93 4283 Autogen conn tiss graft pro-rcpnt&dnr $286 $122

ADA Code

ADA Code

ADA CodeIn

-Net

work

Me

mbe

r Cos

t

In-N

etwo

rk

Mem

ber C

ost

In-N

etwo

rk

Mem

ber C

ost

Out o

f Net

work

Pla

n Pa

ys to

Den

tist

Patie

nt P

ays D

iffer

ence

Out o

f Net

work

Pla

n Pa

ys to

Den

tist

Patie

nt P

ays D

iffer

ence

Out o

f Net

work

Pla

n Pa

ys to

Den

tist

Patie

nt P

ays D

iffer

ence

Procedure Name

Procedure Name

Procedure Name

continued on next page

Page 6: Presbyterian Medicare Advantage Plans · 2790 Crown full cast high nbl mtl $582 $249 2791 Crown full cast predom base mtl $480 $206 2792 Crown full cast noble metal $515 $221 2794

ADA Code

ADA Code

ADA CodeIn

-Net

work

Me

mbe

r Cos

t

In-N

etwo

rk

Mem

ber C

ost

In-N

etwo

rk

Mem

ber C

ost

Out o

f Net

work

Pla

n Pa

ys to

Den

tist

Patie

nt P

ays D

iffer

ence

Out o

f Net

work

Pla

n Pa

ys to

Den

tist

Patie

nt P

ays D

iffer

ence

Out o

f Net

work

Pla

n Pa

ys to

Den

tist

Patie

nt P

ays D

iffer

ence

Procedure Name

Procedure Name

Procedure Name

4285 Non-autogen conn tiss grft pro-inc rcpnt+dnr $260 $112 4320 Provisional splintiing intracoronal $198 $85 4321 Provisional splinting extracoronal $214 $92 4341 Root planing/perio scal 4/ more cont. $117 $50 4342 Root plan/perio scal-1 to 3 per quad $71 $31 4346 Scal in pres of gen mod or sev ging infl $92 $39 4355 Full mouth debrid to enable eval & dx sub vst $67 $29 4381 Localized delivery of chemotherapeutic agents $44 $19 4910 Periodontal maintenance $67 $29 4920 Unsched dress chng by staff $46 $20 4921 Gingival irrigation-per quadrant $11 $5 4999 Unspecified perio proc by report

REMOVABLE PROSTHODONTICS 5110 Complete denture, upper $812 $348 5120 Complete denture, lower $812 $348 5130 Immediate denture - maxillary $868 $372 5140 Immediate denture - mandibular $868 $372 5211 Upper part dent, resin w clas rsts tth $544 $233 5212 Lower part dent resin w clsp rsts & tth $544 $233 5213 Max part dent-cst mtl w res incl clsps, rsts, $774 $332 5214 Mand part dent cast mtl w res incl clsps, rsts $774 $332 5223 Immed max part dent- cst mtl fwk w/res bse $750 $435 5224 Immed man part dent cse mtl fwk w/res bse $750 $435 5225 Max part dent -flex bse incl any clsps,rst $720 $359 5226 Man part den - flex bse incl any clsps,rsts $720 $359 5281 Remov uni part dent, w pontics $431 $185 5282 Remov uni part dent 1 pce cast mtl-max $552 $236 5283 Adjust comp dent-max $552 $236 5284 Remove unilat part dent 1pc flexible pr qd $529 $227 5410 Adjust comp dent upper $38 $16 5411 Adjust complete denture lower $38 $16 5421 Adjust partial denture upper $39 $17 5422 Adjust partial denture lower $39 $17 5511 Repair broken comp dent base, mand $37 $87 5512 Repair broken comp dent base, max $37 $87 5520 Replace missing/broken teeth, com.dent $31 $71 5611 Repair resin part dent base, mand $40 $78 5612 Repair resin partial denture base, maxi $40 $78 5621 Repair cast part fwk, mand $93 $97 5622 Repair cast part fwk, max $93 $97 5630 Repair or replace broken clasp - per tth $106 $45 5640 Replace broken teeth - per tth $64 $28 5650 Add tooth to exist part dent $76 $33 5660 Add clasp to existing part dent- per tooth $97 $41 5670 Replace all tth & acrylic on cst mtl fwk (max) $458 $196 5671 Rpl all tth & acr on cst mtl fwk (mand) $466 $200 5710 Rebase complete upper/lower denture $239 $103 5711 Rebase complete mandibular denture $239 $103 5720 Rebase comp upper/ lower part dent $252 $108 5721 Rebase mandibular partial denture $252 $108 5730 Reline comp upper/lower dent, chair $146 $62 5731 Reline comp mand dent (chair) $146 $62 5740 Reline upper/lower part dent chair $129 $55 5741 Reline part mand dent (chair) $129 $55 5750 Reline comp up/low dent, lab $214 $92 5751 Reline complete mand dent (lab) $214 $92 5760 Reline upper/lower part dent lab $217 $93 5761 Overdenture partial, by report $217 $93 5810 Interim complete denture-maxllary $349 $150 5811 Interim complete denture-mandibular $349 $150

5820 Interim partial denture-maxillary $290 $124 5850 Tissue condition, upper/lower dent $290 $124 5851 Tissue condition - mandibular $69 $29 5860 Overdenture complete report $1,036 $444 5861 Overdenture partial by report $1,036 $444 5862 Precision attach by report B/R B/R 5867 Replace replaceable part semi-prec/prec att $100 $43 5875 Modif remov prosth follow implnt surg $356 $152 5993 Maint & clean of max prosth $140 $60

FIXED PROSTHODONTICS 6210 Pontic cast high noble metal $504 $216 6211 Pontic cast predominantly base metal $419 $179 6212 Pontic cast noble metal $473 $203 6214 Pontic porcelain fused to high noble metal $441 $189 6240 Pontic porcelain fused to high noble metal $538 $230 6241 Pontic porc fused to predom base met $468 $200 6242 Pontic porcelain fused to noble metal $494 $212 6549 Resin retain-for resin bonded fixed prothesis $245 $105 6600 Retainer inlay/porc/ceramic 2 surfaces $440 $189 6601 Retainer inlay porc/ceramic 3 surfaces $447 $192 6602 Retain inlay - cast high nbl mtl 2 surfaces $431 $185 6603 Retainer inlay - cast high nbl mtl 3/more surf $445 $191 6604 Retainer inlay - cast predom base mtl 2 surf $366 $157 6605 Retainer inlay - cast predom base mtl 3/more $397 $170 6606 Retainer inlay - cast nbl mtl 2 surfaces $395 $169 6607 Retainer inlay - cast noble mtl 3/more surf $443 $190 6608 Retainer onlay porc/ceramic 2 surf $494 $212 6609 Retainer onlay porc/ceramic 3/more surf $566 $243 6610 Retainer onlay - cast high nbl mtl 2 surf $474 $203 6611 Retainer onlay - cast high nbl mtl 3/more surf $524 $224 6612 Retainer onlay - cst predom bse mtl 2 surf $457 $196 6613 Retain onlay - cst predom bse mtl 3/more $490 $210 6614 Retainer onlay - cast noble metal 2 surf $491 $210 6615 Retainer onlay - cst nbl mtl 3 /more surf $519 $223 6624 Retainer inlay titanium $450 $193 6634 Retainer onlay titanium $528 $226 6740 Retainer crown - porcelain/ceramic $566 $265 6750 Retain crown porc fused to high nbl mtl $571 $245 6751 Retain crown - porc fuse to predom bs mtl $480 $206 6752 Retainer crown - porce fused to nbl mtl $522 $224 6753 Retainer crown titanium/alloys $553 $237 6780 Retainer crown - 3/4 cast high noble metal $554 $237 6781 Retainer crown - 3/4 cast predom bse mtl $458 $196 6782 Retainer crown - 3/4 cast noble metal $467 $200 6783 Retainer crown - 3/4 porcelain/ceramic $515 $221 6784 Retainer crown 3/4 titanium/alloys $559 $240 6790 Retainer crown - full cast high noble mtl $566 $263 6791 Retainer crown - full cast predom bs mtl $467 $200 6792 Retainer crown - full cast noble metal $515 $221 6793 Prov retain crown-ftx $167 $72 6794 Retainer crown-titanium $566 $243 6920 Connector bar $349 $149 6930 Recement bridge $61 $26 6940 Stress breaker $182 $78 6950 Precision attachment $247 $106 6976 Each additional cast post-same tooth $98 $42 6980 Bridge repair, by report $227 $97 6985 Pediatric partial denture fixed $89 $38

ORAL SURGERY 7111 Extract, coronal remnants, primary tth $35 $15 7140 Extract erupt tth or exposed rt $60 $26 7210 Extraction of tooth - erupted $111 $47 7220 Removal of impacted tooth - soft tissue $122 $52 7230 Removal of impacted tooth - partial bony $190 $82 7510 Incision & drain of abscess, intra soft tiss $107 $46 7511 Incision & drain of abscess-extraoral $205 $88 7520 Incision & drainage of abscess, extraoral soft $149 $64 7521 Incision &drain of abscess intraoral $269 $115 7995 Repair of Maxiof soft/hard tiss defect $657 $281 7960 Frenulectomy-Separate $179 $77 7963 Frenulectomy $171 $73 7970 Excision of hyperplastic tissue, per arch $245 $105

ORTHODONTICS 8010 Limited ortho tx of the primary dentiton $1,495 $641 8090 Comprehensive ortho tx of the adult dentition $3,949 $1,693 8210 Removable appliance therapy $501 $215 8220 Fixed appliance therapy $604 $259 8660 Pre-ortho tx exam to monitor growth/devel $215 $92 8670 Periodic orthodontic tx visit $176 $76 8680 Ortho reten/remov appli $455 $195 8681 Remov ortho retainer adjust $36 $16 8690 Orthodontic tx (alternative billing) $118 $51 8691 Repair of orthodontic appliance $73 $31 8692 Replacement of lost or broken retainer $157 $67 8693 Re-cement fixed retainers $151 $65 8695 Removal of fixed ortho appl $27 $12 8696 Repair of ortho appliance max $77 $33 8697 Repair of ortho appliance mand $77 $33

OTHER SERVICES 9110 Palliative emergency treatment of pain, minor $27 $63 9120 Fixed partial denture sectioning $27 $62 9130 Tempo jnt dysfunct-non-invasive B/R B/R 9210 Local anesth not in conjunct $10 $24 9211 Regional block anesthesia $10 $23 9212 Trigeminal division block anesthesia $17 $39 9215 Local anesthesia $12 $27 9219 Eval for deep sedation/general anesthesia $17 $39 9222 Deep sedation $35 $83 9223 Deep sedation/gen anesthesia $35 $83 9230 Analgesia, anxiolysis, inhal nitrous oxide $12 $28 9239 Intravenous sed/analgesia $56 $56 9243 Intraven mod (cons) sed/analgesia $56 $56 9248 Non-intravenous (conscious) sedation $20 $46 9310 Consultation (other than treating dentist) $41 $18 9410 House/extended care facility call $38 $16 9420 Hospital call $98 $42 9430 Office visit for observation $12 $27 9440 Office visit after regular hours $65 $28 9450 Case present tx plan $36 $15

2020BenefitSource | 1804 Juan Tabo NE, Suite A, Albuquerque, NM 87112 | 888 862 8659 | 505 237 1501 | BenefitSource.org

Page 7: Presbyterian Medicare Advantage Plans · 2790 Crown full cast high nbl mtl $582 $249 2791 Crown full cast predom base mtl $480 $206 2792 Crown full cast noble metal $515 $221 2794

For more information: 1804 Juan Tabo NE, Suite A, Albuquerque, NM 87112

888 862 8659 | 505 237 1501 | BenefitSource.org


Recommended