Unit Stats Govrnmnt Aountability Offi Rport to th Chairman, Subommitt on Primary Halth an Aging, Committ on Halth, Euation, Labor, an Pnsions, U.S. Snat Sptmbr 2013 DENTAL SERVICES Information on Covrag, Paymnts, an F Variation GAO-13-754
Sptmbr 2013 DENTAL SERVICES Information on Covrag, Paymnts, an F Variation Highlights of GAO-13-754, a rport to th Chairman, Subommitt on Primary Halth an Aging, Committ on Halth, Euation, Labor, an Pnsions, U.S. Snat Why GAO Di This Stuy High rats of ntal isas rmain prvalnt aross th nation, spially in vulnrabl an unrsrv populations. Aoring to national survys, 42 prnt of aults with tooth or mouth problms i not s a ntist in 2008 baus thy i not hav ntal insuran or oul not affor th out-of-pokt paymnts, an in 2011, 4 million hilrn i not obtain n ntal ar baus thir familis oul not affor it. In 2011, th Institut of Miin rport that thr is strong vin that ntal ovrag is positivly ti to ass to an us of oral halth ar. For familis without ntal ovrag, frally fun halth ntrs may offr an afforabl ntal ar option. Halth ntrs ar rquir to offr sliing f shuls with isounts of up to 100 prnt for many low-inom patints. GAO was ask to xamin ntal srvis in th Unit Stats. This rport sribs (1) trns in ovrag for, an us of, ntal srvis; (2) trns in paymnts by iniviuals an othr payrs for ntal srvis; an (3) th xtnt to whih ntal fs vary btwn an within slt ommunitis aross th nation. To o this work, GAO xamin HHS national halth survy ata an national ntal xpnitur stimats, ntal insuran laims ata, an halth ntr ntal fs in 18 slt ommunitis (bas on nsus rgion, population, an ntal laims volum). GAO also intrviw HHS offiials an aami xprts. HHS provi thnial ommnts on a raft of this rport, whih wr inorporat as appropriat. Viw GAO-13-754. For mor information, ontat Kathrin Iritani at (202) 512-7114 or iritanik@gao.gov. What GAO Foun Ovrall, trns in ntal ovrag show littl hang from 1996 to 2010 aroun 62 prnt of iniviuals ha ovrag. Th prntag of th population with privat ntal ovrag ras from 53 to 50 prnt (s fig.). Dntal ovrag through Miai or th Stat Chilrn s Halth Insuran Program (CHIP), whih was stablish in 1997, ros from 9 to 13 prnt. Th inras was u primarily to an inras in th numbr of hilrn ovr by ths fral-stat halth programs with manat piatri ntal ovrag. Iniviuals with no ntal ovrag ras from 28 to 25 prnt, an ovrag for 10 to 12 prnt of th population was unknown. Us of ntal srvis th prntag of iniviuals who ha at last on ntal visit also rmain rlativly unhang at aroun 40 prnt from 1996 to 2010. Miai an CHIP bnfiiaris, hilrn in partiular, show inrass in th us of ntal srvis (from 28 to 37 prnt), but still visit th ntist lss oftn than privatly insur hilrn (58 prnt in 2010). Dntal Covrag Status, 1996 an 2010 Not: For 2010, Miai inlu hilrn in th Stat Chilrn s Halth Insuran Program. GAO s analysis show that avrag annual ntal paymnts th total amount pai out of pokt by iniviuals an by othr payrs inras 26 prnt, inflation-ajust, from $520 in 1996 to $653 in 2010. Avrag annual out-ofpokt paymnts inras 21 prnt, from $242 to $294, for iniviuals with privat insuran an 32 prnt, from $392 to $518, for iniviuals with no ntal ovrag. Dntal fs harg by loal ntists an halth ntrs vari wily. For 8 of 24 ommon prours GAO xamin, rport uppr-n fs (th 95 th prntil of th rang in loal ntist fs) wr at last oubl th mipoint fs (th 50 th prntil of th rang in loal ntist fs) in svral ommunitis. For xampl, in Miami, Floria, th uppr-n f of $150 for a prioi oral xamination was mor than twi th mipoint ntal f of $62. Dntal fs also vari btwn loal ntists billing privat insurrs an halth ntrs srving rsints of th sam ommunity. In gnral, most halth ntrs in GAO s rviw offr a 100 prnt isount rsulting in no f to th lowst-inom patints for many, but not all, ntal srvis. Unit Stats Govrnmnt Aountability Offi
Contnts Lttr 1 Bakgroun 6 National Survy Data Show That Rats of Dntal Covrag an Us of Dntal Srvis Rmain Gnrally Unhang from 1996 to 2010 10 Avrag Paymnts for Dntal Srvis Inras from 1996 to 2010 18 Fs Charg for Dntal Srvis Vari btwn an within Communitis 22 Agny Commnts 30 Appnix I National Dntal Expniturs 32 Appnix II Urban an Rural Dntal Visit Rats 33 Appnix III Sop an Mthoology 34 Appnix IV Dntal Fs Charg for Common Dntal Prours in 18 Communitis 38 Appnix V GAO Contat an Staff Aknowlgmnts 74 Rlat GAO Prouts 75 Tabls Tabl 1: Catgoris an Exampls of Dntal Srvis 6 Tabl 2: Dsriptions of Dntal Covrag within Crtain Fral Halth Programs 8 Tabl 3: Prntag of Iniviuals with a Dntal Visit, 1996, 2004, an 2010 15 Tabl 4: Prntag of Iniviuals with a Dntal Visit, by Covrag Status, 1996, 2004, an 2010 15 Pag i
Tabl 5: Avrag Annual Dntal Paymnts for Iniviuals with a Dntal Visit, Ajust for Inflation, by Covrag Status, 1996, 2004, an 2010 18 Tabl 6: Prours with th Largst Prntag Diffrn btwn Mipoint an Uppr-En Fs, 2012 25 Tabl 7: Diffrns btwn Mipoint an Uppr-En Dntal Fs Charg for a Prioi Oral Evaluation of an Establish Patint, by Loal Dntists in 18 Communitis in Nin Stats, 2012 26 Tabl 8: Diffrns btwn Mipoint an Uppr-En Dntal Fs Charg for a Filling by Loal Dntists in 18 Communitis in Nin Stats, 2012 27 Tabl 9: Dntal Fs Charg for a Tooth Extration by Loal Dntists an Halth Cntrs in 18 Communitis in Nin Stats, 2012 29 Tabl 10: Dntal Fs Charg for Common Prours in Phonix, Arizona (850), 2012 38 Tabl 11: Dntal Fs Charg for Common Prours in Flagstaff, Arizona (860), 2012 40 Tabl 12: Dntal Fs Charg for Common Prours in Los Angls, California (900), 2012 42 Tabl 13: Dntal Fs Charg for Common Prours in Frsno, California (936), 2012 44 Tabl 14: Dntal Fs Charg for Common Prours in Miami, Floria (331), 2012 46 Tabl 15: Dntal Fs Charg for Common Prours in Palm Coast, Floria (321), 2012 48 Tabl 16: Dntal Fs Charg for Common Prours in Chiago, Illinois (606), 2012 50 Tabl 17: Dntal Fs Charg for Common Prours in Champaign, Illinois (618), 2012 52 Tabl 18: Dntal Fs Charg for Common Prours in Boston, Massahustts (021), 2012 54 Tabl 19: Dntal Fs Charg for Common Prours in Pittsfil, Massahustts (012), 2012 56 Tabl 20: Dntal Fs Charg for Common Prours in Minnapolis, Minnsota (554), 2012 58 Tabl 21: Dntal Fs Charg for Common Prours in Mankato, Minnsota (560), 2012 60 Tabl 22: Dntal Fs Charg for Common Prours in Nw York, Nw York (100), 2012 62 Pag ii
Tabl 23: Dntal Fs Charg for Common Prours in Elmira, Nw York (148), 2012 64 Tabl 24: Dntal Fs Charg for Common Prours in Nashvill, Tnnss (372), 2012 66 Tabl 25: Dntal Fs Charg for Common Prours in Jakson, Tnnss (382), 2012 68 Tabl 26: Dntal Fs Charg for Common Prours in Dallas, Txas (752), 2012 70 Tabl 27: Dntal Fs Charg for Common Prours in San Anglo, Txas (768), 2012 72 Figurs Figur 1: Dntal Covrag Status, 1996, 2004, an 2010 12 Figur 2: Rats of Privat Dntal Covrag, by Inom Lvl, 1996, 2004, an 2010 13 Figur 3: Dntal Covrag Rats for Chilrn, Ags 0-20 Yars, 1996, 2004, an 2010 14 Figur 4: Prntag of Chilrn, Ags 0-20 Yars, with Privat an Miai Dntal Covrag with a Dntal Visit, 1996, 2004, an 2010 16 Figur 5: Typs of Dntal Srvis as a Proportion of Total Srvis, 1996, 2004, an 2010 17 Figur 6: Avrag Annual Paymnts for Dntal Srvis for Iniviuals with a Dntal Visit, Ajust for Inflation, by Inom Lvl, 1996, 2004, an 2010 20 Figur 7: Avrag Annual Out-of-Pokt Paymnts for Iniviuals with a Dntal Visit, 1996, 2004, an 2010 21 Figur 8: Mipoint Dntal Fs in 18 Communitis for Tth Claning (Ault an Chil), 2012 23 Figur 9: National Expniturs for Dntal Srvis, Ajust for Inflation, 1996-2011 32 Figur 10: Prntag of Iniviuals with a Dntal Visit, by Ag an Loation, 2008-2010 33 Pag iii
Abbrviations ADA AHRQ CDT CHIP CMS CPI-U FPL HHS HRSA MEPS PPACA VA Amrian Dntal Assoiation Agny for Halthar Rsarh an Quality Currnt Dntal Trminology Stat Chilrn s Halth Insuran Program Cntrs for Miar & Miai Srvis Consumr Pri Inx for All Urban Consumrs fral povrty lvl Dpartmnt of Halth an Human Srvis Halth Rsours an Srvis Aministration Mial Expnitur Panl Survy Patint Prottion an Afforabl Car At Dpartmnt of Vtrans Affairs This is a work of th U.S. govrnmnt an is not subjt to opyright prottion in th Unit Stats. Th publish prout may b rprou an istribut in its ntirty without furthr prmission from GAO. Howvr, baus this work may ontain opyright imags or othr matrial, prmission from th opyright holr may b nssary if you wish to rprou this matrial sparatly. Pag iv
441 G St. N.W. Washington, DC 20548 Sptmbr 6, 2013 Th Honorabl Brnar Sanrs Chairman Subommitt on Primary Halth an Aging Committ on Halth, Euation, Labor, an Pnsions Unit Stats Snat Dar Mr. Chairman: Mor than a a ago, th Surgon Gnral s rport on oral halth srib th poor oral halth of our nation as a silnt pimi. 1 Toay, high rats of ntal isass rmain prvalnt aross th nation, spially in vulnrabl an unrsrv populations. Th ost of ntal ar an lak of ntal ovrag ar oftn it as rasons iniviuals may not sk n ntal ar. 2 In 2008, 42 prnt of aults with tooth or mouth problms rport thy i not s a ntist baus thy i not hav ntal ovrag or oul not affor th out-of-pokt paymnts. 3 Similarly, in 2011, 4 million hilrn i not obtain n ntal ar baus thir familis oul not affor it. 4 Th Institut of Miin has rport that thr is strong vin that ntal ovrag is positivly assoiat with ass to an us of oral halth ar. 5 1 U.S. Dpartmnt of Halth an Human Srvis, National Institut of Dntal an Craniofaial Rsarh, National Instituts of Halth, Oral Halth in Amria: A Rport of th Surgon Gnral (Rokvill, M.: 2000). 2 Iniviuals an obtain ntal ovrag from privat insuran or publi programs inluing Miai, Miar, Vtrans Affairs, or stat sponsor programs. 3 B. Bloom, C.M. Simil, P.F. Aams, an R.A. Cohn, Oral Halth Status an Ass to Oral Halth Car for U.S. Aults Ag 18 64: National Halth Intrviw Survy 2008, Vital an Halth Statistis 10(253) (Hyattsvill, M.: National Cntr for Halth Statistis, 2012). For our rport, insuran prmiums wr not inlu in out-of-pokt paymnts. 4 B. Bloom, R.A. Cohn, an G. Frman, Summary Halth Statistis for U.S. Chilrn: National Halth Intrviw Survy, 2011, Vital an Halth Statistis 10(254) (Hyattsvill, M.: National Cntr for Halth Statistis, 2012). 5 Institut of Miin an National Rsarh Counil, Improving Ass to Oral Halth Car for Vulnrabl an Unrsrv Populations. Th National Aamis Prss (Washington, D.C.: 2011). For xampl, on stuy foun that iniviuals who i not hav ntal insuran wr about two-thirs lss likly to hav a ntal visit than iniviuals with privat insuran. Pag 1
Rognizing that oral halth is ntral to a prson s ovrall halth an wll-bing, th Dpartmnt of Halth an Human Srvis (HHS) has aopt an oral halth objtiv as a laing halth iniator in its Halthy Popl 2020 initiativ, whih onsists of 10-yar national objtivs for improving th halth of all Amrians. 6 Spifially, HHS s laing iniator for oral halth is to inras th proportion of hilrn, aolsnts, an aults who us th oral halth ar systm in th past 12 months. Th 2020 targt for this laing halth iniator is to inras ass to ntal srvis inrasing th proportion of iniviuals ag 2 yars an olr who hav ha a ntal visit in a yar to 49.0 prnt from 44.5 prnt in 2007. Many familis that annot affor ntal ar obtain it from halth ntrs, for whih fral funs provi a substantial part of rvnu. Dntal srvis that ar provi by halth ntrs must b availabl to all patints, rgarlss of thir ability to pay. All halth ntrs must hav f shuls for all srvis, inluing any ntal srvis provi, that rflt prvailing fs in th ara an a shul of isounts (or sliing f shul) for iniviuals who arn annual inoms qual to or lss than 200 prnt of th fral povrty lvl (FPL). You ask us to xamin ntal ovrag, an us of an paymnts for ntal srvis in th Unit Stats. This rport sribs (1) trns in ovrag for an us of ntal srvis, (2) trns in paymnts for ntal srvis ma by iniviuals an othr payrs, an (3) th xtnt to whih ntal fs vary btwn an within slt ommunitis aross th nation. You also ask us to xamin national xpniturs for ntal srvis. W rport national ntal xpniturs from 1996 through 2011 in appnix I. To provi information on trns in ntal ovrag an th us of ntal srvis by typ of ovrag, w obtain an analyz ata fils from th Mial Expnitur Panl Survy (MEPS) for 1996, 2004, an 2010 on ntal visits, ntal srvis, an ovrag status. W slt ths 6 Halthy Popl 2020 is an HHS initiativ that provis sin-bas, 10-yar national objtivs for improving th halth of all Amrians. Halthy Popl stablishs bnhmarks an monitors progrss ovr tim in orr to nourag ollaborations aross ommunitis an stors, mpowr iniviuals towar making inform halth isions, an masur th impat of prvntion ativitis. S http://www.halthypopl.gov/about/fault.aspx for mor information. Pag 2
yars for our analysis baus 1996 was th first yar MEPS was aministr an 2010 was th most rnt yar for whih ata wr availabl; w inlu 2004 to provi thr points in tim for our analysis. MEPS is aministr by HHS s Agny for Halthar Rsarh an Quality (AHRQ) an is a nationally rprsntativ survy of th noninstitutionaliz population, inluing familis, mial provirs, an mployrs aross th Unit Stats. W bas our analysis on a similar analysis onut by AHRQ for its Chartbook 17 publiation. 7 W analyz ata on ntal ovrag an ntal visits (inluing th atgory of srvi obtain uring th visit, suh as prvntiv or rstorativ) pr yar, as wll as iffrns in ovrag status an ntal visits bas on mographis suh as ag group an inom lvl. W also xamin us of ntal srvis by iniviuals in urban an rural aras; to nsur aquat sampl sizs, w ombin svral yars of MEPS ata. Information for th urban an rural analysis is prsnt in appnix II. MEPS ollts information on privat ntal ovrag but os not ollt information spifially about whthr ntal ovrag is inlu in halth plans offr by publi programs suh as halth ovrag provi by th Dpartmnt of Vtrans Affairs (VA), Dpartmnt of Dfns (DOD), or Miar Avantag. 8 Thrfor, w oul not trmin for this population whthr thos iniviuals ha ntal ovrag, an w atgoriz that group as unknown. To intify trns in ntal paymnts by iniviuals an othr payrs, that is, how muh iniviuals pai out of pokt for ntal ar an how muh ntal insurrs or othr payrs, suh as Miai, pai for ntal laims, w obtain an analyz MEPS 1996, 2004, an 2010 ata fils on 7 Chartbook 17 xamin MEPS ata rlat to ntal ovrag, us, an paymnts in 1996 an 2004. R.J. Manski an E. Brown, Dntal Us, Expnss, Privat Dntal Covrag, an Changs, 1996 an 2004, MEPS Chartbook No.17 (Rokvill, M.: Agny for Halthar Rsarh an Quality, 2007). S http://www.mps.ahrq.gov/mpswb/ata_fils/publiations/b17/b17.pf. 8 Miar Part A ovrs hospital an othr inpatint stays. Miar Part B is optional insuran an ovrs hospital outpatint, physiian, an othr srvis. Miar bnfiiaris hav th option of obtaining ovrag for Miar Part A an B srvis from privat halth plans that partiipat in th Miar Avantag program also known as Miar Part C. Miar Avantag is a privat plan altrnativ to traitional Miar f-for-srvi an may provi bnfits, suh as ntal ovrag, not inlu in traitional Miar f-for-srvi. In 2010, about 25 prnt of Miar bnfiiaris wr nroll in Miar Avantag plans. Pag 3
ntal visits, paymnts, an ovrag status. 9 In aition, w analyz varians by mographi group, inluing ag group an inom lvl. To trmin th xtnt to whih ntal fs vari btwn an within rtain ommunitis, w analyz ntal laims ata ompil by FAIR 10 Halth, In. as of January 2013, an obtain ntal f shuls from slt frally fun halth ntrs. Th FAIR Halth ntal ata st ontains ovr 140 million laims, inluing gozip ata (th first 3 igits of a postal zip o 11 ) an Amrian Dntal Assoiation (ADA) Currnt Dntal Trminology (CDT) billing os. 12 W slt 24 ntal prours for omparison by intifying th CDT billing os with th most ntal laims in ah of six atgoris of ntal srvis fiv os ah for iagnosti, prvntiv, an rstorativ srvis; an thr ah for noonti, prioonti, an oral surgry srvis. Aami xprts an ADA offiials agr that our list of 24 CDT os was rprsntativ of th most ommon ntal prours. To slt larg ommunitis, w intifi th gozip with th most ntal laims in th or ity in th largst mtropolitan statistial ara in ah of th nin U.S. Cnsus Burau ivisions. 13 For omparison to our larg ommunitis, w slt nin small ommunitis in th sam stats bas on thir population. Baus gozip bounaris o not align with 9 For this rport, w rfr to MEPS ntal xpnss as ntal paymnts. 10 FAIR Halth, In., is an inpnnt, not-for-profit orporation that ompils ntal an mial laims ata (nonisount fs harg by provirs) from privat insurrs. S http://www.fairhalth.org/ for mor information about FAIR Halth, In., an its ntal laims ata st. 11 FAIR Halth uss th trm gozip to rfr to an ara ovr by th first 3 igits of a postal zip o. Th U.S. Postal Srvi sribs a 3-igit zip o as th ara srv by a stional ntr faility, whih is a prossing an istribution ntr for all zip os bginning with thos 3 igits. Largr itis an inlu multipl 3-igit zip os. For xampl, th Los Angls/Long Bah mtropolitan ara inlus gozips 900 to 912 (xluing 909). 12 Cos on Dntal Prour an Nomnlatur ar th intlltual proprty of th ADA as opyright ownr. 13 Th U.S. Offi of Managmnt an Bugt linats mtropolitan statistial aras aoring to publish stanars that ar appli to Cnsus Burau ata. Th gnral onpt of a mtropolitan statistial ara is that of a or ara ontaining a substantial population nulus, togthr with ajant ommunitis having a high gr of onomi an soial intgration with that or. Th Cnsus Burau has nin ivisions: Nw Englan, Mil Atlanti, East North Cntral, Wst North Cntral, South Atlanti, East South Cntral, Wst South Cntral, Mountain, an Paifi. Pag 4
mtropolitan statistial ara signations, w slt on gozip (th on with th most ntal laims) to rprsnt ah larg an ah small mtropolitan ara. W xamin th 50 th prntil ntal f an th 95 th prntil ntal f for ah of our 24 CDT os from a gozip in ah larg an small ommunity. 14 To intify ntal fs harg by frally fun halth ntrs, w obtain oumntation an mt with offiials from HHS s Halth Rsours an Srvis Aministration (HRSA), whih aministrs th Halth Cntr Program. HRSA provi a list of halth ntrs that srv rsints of our 18 slt ommunitis an that provi ntal srvis. W obtain full f an sliing f shuls from on halth ntr that srv ah ommunity, although som halth ntrs i not provi or bill sparatly for all 24 prours. To trmin th rliability of th MEPS, FAIR Halth, an halth ntr ata, w rviw rlat oumntation, talk to agny offiials an aami xprts, an rviw othr stuis that us th ata to arss similar rsarh qustions. W trmin that th MEPS, FAIR Halth, an halth ntr ata wr suffiintly rliabl for th purposs of our rport. W onut this prforman auit from Otobr 2012 to Sptmbr 2013 in aoran with gnrally apt govrnmnt auiting stanars. Thos stanars rquir that w plan an prform th auit to obtain suffiint, appropriat vin to provi a rasonabl basis for our finings an onlusions bas on our auit objtivs. W bliv that th vin obtain provis a rasonabl basis for our finings an onlusions bas on our auit objtivs. (For mor information on our sop an mthoology, s app. III.) 14 Prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 95 prnt of rport fs fall blow th 95 th prntil. Pag 5
Bakgroun Dntal Srvis Dntal srvis ovr an array of prours, from prvntiv srvis, suh as lanings, to mor omplx srvis, suh as root anals (s tabl 1). Tabl 1: Catgoris an Exampls of Dntal Srvis Catgory Exampls Diagnosti X-ray Examination Prvntiv Claning Fluori appliation Salant appliation Rstorativ Fillings Crowns Enoonti Root anal Prioonti Tratmnt of th gums Oral Surgry Surgial rmoval of a tooth Sour: GAO summary of Amrian Dntal Assoiation (ADA) information. Dntal Covrag Most iniviuals with ntal ovrag hav privat ntal insuran. Privat ntal insuran plans may b a stan-alon plan or b inlu as a part of mial insuran. Stan-alon ntal plans rquir iniviuals to nroll sparatly; thy ar not a part of th iniviual s mial insuran plan. Th typs of ntal srvis ovr by ntal plans vary wily among privat plans. For xampl, on plan may inlu omprhnsiv ar suh as routin iagnosti an prvntiv srvis, rstorativ srvis, an oral surgry, whil anothr may ovr mor limit srvis suh as mrgny ar only. Cost sharing for ntal srvis usually involvs an annual utibl an aoring to a Burau of Labor Statistis survy of mployrs, in 2008, th mian utibl was $50 pr prson. 15 Aftr th iniviual mts th 15 Burau of Labor Statistis, Slt Mial Bnfits: A Rport from th Dpartmnt of Labor to th Dpartmnt of Halth an Human Srvis (Washington, D.C.: Apr. 15, 2011). This survy was onut by th Burau of Labor Statistis of mployrsponsor halth plans to trmin th bnfits typially ovr by mployrs. Pag 6
utibl, ntal plans may pay a prntag of ovr srvis up to a maximum annual bnfit. In 2008, th rport mian annual maximum was $1,500. Iniviuals may also obtain ntal ovrag in othr ways, suh as through fral programs. Fral programs may ovr ntal srvis as a rquir bnfit, support purhas of stan-alon ntal ovrag for ligibl bnfiiaris, or support ovrag of ntal srvis as part of broar ovrag unr iniviuals mial ovrag plans, for xampl. Bnfits inlu in ths typs of ovrag may vary wily pning on fators suh as typ of plan purhas, family inom, or vtran s status (s tabl 2). Pag 7
Tabl 2: Dsriptions of Dntal Covrag within Crtain Fral Halth Programs Program Miai a an Stat Chilrn s Halth Insuran Program (CHIP) Miar Dpartmnt of Vtrans Affairs (VA) Dpartmnt of Dfns TRICARE Dsription of ntal ovrag For hilrn in Miai, unr th Early an Prioi Srning, Diagnosti, an Tratmnt bnfit, stat Miai programs must provi ntal srvis, inluing iagnosti, prvntiv, an rlat tratmnt srvis, for all ligibl Miai bnfiiaris unr ag 21. For aults in Miai, ntal ovrag varis, as stats hav flxibility to trmin whthr to provi ntal bnfits for aults an if so, what srvis to inlu. For xampl, whil many stats ovr som ntal srvis for aults, suh as prvntiv xams, othr stats o not, limiting this bnfit to trauma ar or mrgny tratmnt for pain rlif an inftion. Stats may also rquir that rtain srvis hav prior approval, or pla limits on th total amount of srvis an nroll an riv ah yar. Whn CHIP was stablish in 1997, ovrag of ntal srvis was not a rquir bnfit. b Th Chilrn s Halth Insuran Program Rauthorization At of 2009 xpan fral rquirmnts for CHIP programs to ovr ntal srvis. Spifially, th at rquir stats to ovr ntal srvis in thir CHIP programs bginning in Otobr 2009. It also gav stats authority to us bnhmark plans to fin th bnfit pakag or to supplmnt hilrn s privat halth insuran with a ntal ovrag plan finan through CHIP. Stats that provi CHIP ovrag to hilrn through a Miai xpansion program ar rquir to provi th Early an Prioi Srning, Diagnosti, an Tratmnt bnfit. Stats with a sparat CHIP program may hoos from two options for proviing ntal ovrag: a pakag of ntal bnfits that mts th CHIP rquirmnts, or a bnhmark ntal bnfit pakag that is substantially qual to th (1) most popular fral mploy ntal plan for pnnts, (2) most popular plan slt for pnnts in th stat s mploy ntal plan, or (3) ntal ovrag offr through th most popular ommrial insurr in th stat. Gnrally, Miar os not ovr routin prvntiv or rstorativ ntal srvis. Miar f-for-srvi offrs ntal ovrag unr limit irumstans, for xampl, proviing ntal srvis that ar an intgral part of a ovr prour (.g., ronstrution of th jaw following aintal injury). Miar Avantag plans hav th flxibility to offr ovrag of routin prvntiv an rstorativ ntal srvis. Miar ntal ovrag varis by typ of Miar Avantag plan slt by bnfiiaris. VA ovrag of ntal srvis rquirs nrollmnt, an xat ovrag of ntal srvis varis by an iniviual vtran s status for xampl, whthr th vtran has a srvi-onnt isability. In som instans, VA may provi omprhnsiv ntal ar, whil in othr ass ovr ntal srvis may b limit. For xampl, som vtrans with srvi-onnt isabilitis ar ligibl for any nssary ntal ar. Othr vtrans ar only ligibl for ntal ar if thir ntal problms may ompliat xisting mial onitions. TRICARE th Dpartmnt of Dfns s rgionally strutur halth ar systm offrs ntal bnfits as a sparat program that for many bnfiiaris rquirs sparat nrollmnt. Th TRICARE Dntal Program an TRICARE Rtir Dntal Program ar voluntary an rquir nrollmnt. Th TRICARE Ativ Duty Dntal Program supplmnts srvis provi at military ntal tratmnt failitis for ativ uty srvi mmbrs. Bnfits vary by program an ligibility for xampl, familis may hav to purhas a supplmntal ntal poliy outsi of thir mial ovrag to obtain ntal ovrag. Sour: GAO summary of agny information. a Miai, a joint fral an stat program that provis halth ar ovrag for rtain low-inom iniviuals an familis, provi halth ovrag for an stimat 70 million nrolls in fisal yar Pag 8
2011. Stats oprat thir Miai programs within broa fral rquirmnts an may ontrat with manag ar organizations to provi Miai mial an ntal bnfits. b Stats an aministr thir CHIP programs as (1) an xpansion of thir Miai program, (2) a stan-alon program, or (3) a ombination of Miai xpansion an stan-alon. Pub. L. No. 111-3, 501, 123 Stat. 8, 84. Miar Part A ovrs hospital an othr inpatint stays. Miar Part B is optional insuran an ovrs hospital outpatint, physiian, an othr srvis. Miar bnfiiaris hav th option of obtaining ovrag for Miar Part A an B srvis from privat halth plans that partiipat in th Miar Avantag program also known as Miar Part C. In 2010, about 25 prnt of Miar bnfiiaris wr nroll in Miar Avantag plans. Miar Avantag is a privat plan altrnativ to traitional Miar f-for-srvi an may provi bnfits, suh as ntal ovrag, not inlu in traitional Miar f-for-srvi. Dntal Car Provi by Halth Cntrs HHS s HRSA rport that in 2011, ovr 4 million patints us ntal srvis at frally fun halth ntrs. 16 Unr th Halth Cntr Program, halth ntrs whih must b loat in frally signat mially unrsrv aras or srv a frally signat mially unrsrv population ar rquir to provi piatri ntal srnings an prvntiv ntal srvis, as wll as mrgny mial rfrrals, whih may also rsult in th provision of ntal srvis. Halth ntrs may provi rquir srvis, inluing rquir ntal srvis, irtly or via formal ontrat or rfrral agrmnts. Howvr, halth ntrs ar not rquir to provi a full rang of ntal srvis. A halth ntr must stablish a f shul for its srvis that is onsistnt with loally prvailing rats an rflts th halth ntr s rasonabl osts of proviing srvis. A halth ntr must also stablish a sliing f shul for iniviuals who arn annual inoms 17 qual to or lss than 200 prnt of th FPL. HRSA rport that in 2011, ovr 92 prnt of th mor than 20 million patints srv by halth ntrs nationwi ha inom lss than or qual to 200 prnt of th FPL (an wr ligibl for a sliing sal f bas on inom an family siz). 18 16 42 U.S.C. 254b. Halth ntrs ar fun in part through grants unr th Halth Cntr Program aministr by HRSA an provi omprhnsiv primary ar srvis for th mially unrsrv. 17 Th 2013 fral povrty guilins stat that a family of four at 200 prnt of th povrty lvl has an inom of $47,100 pr yar. 18 Aoring to HRSA offiials, ata spifi to ntal patints wr not availabl. Pag 9
Dntal Car unr th Patint Prottion an Afforabl Car At Th Patint Prottion an Afforabl Car At (PPACA) has signat piatri ntal ar as an ssntial halth bnfit that nw halth plans must ovr in th nw halth ar xhangs an th small-group an iniviual markts. Exhangs may allow plans to offr stan-alon ntal ovrag proviing, at a minimum, piatri ntal ar. Ault ntal ovrag is not inlu as an ssntial halth bnfit. Plans that hav granfathr status unr th law ar not rquir to offr piatri ntal ovrag. 19 PPACA has th potntial to hang th bnfits an out-of-pokt paymnts assoiat with ntal ovrag; howvr, th xtnt of ths hangs is unrtain. National Survy Data Show That Rats of Dntal Covrag an Us of Dntal Srvis Rmain Gnrally Unhang from 1996 to 2010 Covrag of Dntal Srvis Rmain Rlativly Unhang from 1996 to 2010 Th rat of iniviuals with ntal ovrag rmain largly unhang from 1996 to 2010; aroun 62 to 63 prnt of th population ha privat or Miai or CHIP ntal ovrag. In aition, from 1996 to 2010, th prntag of iniviuals who ha a ntal visit rmain about th sam, aroun 41 to 43 prnt. Our analysis of MEPS ata show that ovrall, th rat of ntal ovrag th prntag of iniviuals rporting that thy ha ntal ovrag through privat insuran or Miai or CHIP rmain rlativly unhang from 1996 to 2010. 20 Spifially, in 1996, 62 prnt of iniviuals rport having ntal ovrag, an in 2010, 63 prnt rport having ntal ovrag. For about 10 to 12 prnt 19 Privat halth ar plans in xistn as of Marh 23, 2010, ar onsir granfathr plans that o not hav to omply with rtain PPACA ovrag rquirmnts. Howvr, plans may los thir granfathr status if thy ut bnfits or inras bnfiiary ost sharing. 20 For purposs of this rport, w rfr to hilrn in Miai an CHIP as hilrn in Miai, baus th MEPS ata o not istinguish btwn hilrn in Miai an CHIP. Pag 10
of th population, inluing many iniviuals ovr by Miar an othr fral halth programs, ntal ovrag status is unknown. 21 Whil th ovrall prntag of iniviuals with ntal ovrag gnrally stay th sam btwn 1996 an 2010, th prntags with privat ntal an without insuran ovrag ras an th prntag with Miai ntal ovrag inras. Spifially, th prntag of iniviuals with privat ovrag was 53 prnt in 1996 an 50 prnt in 2010 (s fig. 1). Th prntag of iniviuals with ntal ovrag unr Miai inras staily in ah of th yars w xamin, from 9 prnt in 1996 to 13 prnt in 2010. Th prntag of iniviuals rporting that thy i not hav ntal ovrag ras from 28 prnt in 1996 to 25 prnt in 2010, laving at last on in four iniviuals with no ntal ovrag approximatly 76 million popl in 2010. For 10 to 12 prnt of iniviuals in ah yar w xamin, it is unknown whthr thy ha ntal ovrag. Ths iniviuals rport having som typ of halth ovrag, suh as Miar ovrag, but th MEPS survy strutur i not allow us to trmin whthr that halth ovrag inlu ntal ovrag. 21 Most of ths iniviuals rport having Miar ovrag. Traitional Miar offrs vry limit ntal bnfits. Miar Avantag plans may inlu ntal ovrag. In 2010, about 25 prnt of Miar bnfiiaris wr in a Miar Avantag plan, but not all plans offr ntal ovrag or offr ntal ovrag as an optional bnfit. Consquntly, this onsrvativ approah may rsult in ovrstating th unknown atgory an unrstating th non atgory. Pag 11
Figur 1: Dntal Covrag Status, 1996, 2004, an 2010 Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This figur inlus only th noninstitutionaliz population. For 2004 an 2010, Miai inlus hilrn nroll in th Stat Chilrn s Halth Insuran Program. Iniviuals in th unknown atgory iniat that thy ha othr typs of publi ovrag, inluing stat or fral programs suh as Miar or vtran s bnfits. Ths programs might not hav inlu ntal ovrag, or might hav provi limit ntal ovrag to rtain iniviuals. For ths programs, th MEPS survy mthoology i not allow us to intify whih bnfiiaris atually ha ntal ovrag. Bnfiiaris in ths programs with a ntal laim pai by privat insuran uring th prio wr ount as having privat ovrag. For xampl, Miar Avantag nrolls who ha a laim pai by privat insuran wr ount in th privat insuran atgory. Miar bnfiiaris who i not hav a laim pai by privat insuran wr inlu in th unknown atgory baus thy might hav ha ntal ovrag, suh as unr a Miar Avantag plan, but i not us thir ovrag uring th survy prio. Rats of privat ntal ovrag among iniviuals in th high-inom atgory (ovr 400 prnt of FPL) wr highr than any othr inom atgory in 1996, 2004 an 2010 (s fig. 2). Iniviuals in th poor-, low-, an mil-inom groups saw a lin in th rats of privat ovrag ovr th sam prio. 22 22 For this analysis, poor iniviuals ar iniviuals in familis with inom at or blow 100 prnt of th FPL. Th low-inom group is iniviuals in familis with inom at or blow 200 prnt of th FPL but abov 100 prnt of th FPL. Iniviuals in th mil-inom group ar thos in familis with inom at or blow 400 prnt of th FPL, but abov 200 prnt of th FPL. Pag 12
Figur 2: Rats of Privat Dntal Covrag, by Inom Lvl, 1996, 2004, an 2010 Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This figur inlus only th noninstitutionaliz population. Inom is xprss in trms of povrty status. For this analysis, poor rfrs to iniviuals in familis with inom at or blow 100 prnt of th fral povrty lvl (FPL). Th low-inom group is iniviuals in familis with inom at or blow 200 prnt of th FPL but abov 100 prnt of th FPL. Th mil-inom group is iniviuals in familis with inom at or blow 400 prnt of th FPL but abov 200 prnt of th FPL. Th high-inom group is iniviuals in familis with inom gratr than 400 prnt of th FPL. Th prntag of iniviuals with Miai ntal ovrag inras from 9 prnt in 1996 to 13 prnt in 2010. This trn was largly rivn by an inras in hilrn ovr by Miai, whih rquirs piatri ntal ovrag. Th ovrall prntag of hilrn (ags 0-20 yars) rport to hav ntal ovrag through privat ovrag or Miai inras from 72 prnt (59 million) in 1996 to 81 prnt (71 million) in 2010, an fwr hilrn wr uninsur, baus mor hilrn wr ovr by Miai in 2010 than in prior yars. Th prntag of hilrn with ntal ovrag through Miai inras from 18 prnt (15 million) in 1996 to 33 prnt (29 million) in 2010 (s fig. 3). This was th largst inras in ovrag for any ag group in Miai. Th prntag of hilrn with privat ntal Pag 13
ovrag ras from 54 prnt (44 million) in 1996 to 48 prnt (42 million) in 2010. In aition, rats of hilrn without ntal ovrag lin from 27 prnt (22 million) to 17 prnt (15 million) ovr th sam prio. Figur 3: Dntal Covrag Rats for Chilrn, Ags 0-20 Yars, 1996, 2004, an 2010 Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This figur inlus only th noninstitutionaliz population. Th unknown atgory for this ag group is not rport in this figur baus of small sampl sizs (fwr than 2 prnt of hilrn ags 0-20 yars wr rport as having unknown ntal ovrag). For 2004 an 2010, Miai inlus hilrn nroll in th Stat Chilrn s Halth Insuran Program. Us of Dntal Srvis Rmain Rlativly Unhang from 1996 to 2010 Th prntag of iniviuals who us ntal srvis thos who rport having at last on ntal visit uring th yar rmain rlativly unhang at aroun 40 prnt from 1996 to 2010. Spifially, about 43 prnt of iniviuals in 1996 an 41 prnt in 2010 ha a ntal visit. Tabl 3 shows our analysis of MEPS ata on th us of ntal srvis. Pag 14
Tabl 3: Prntag of Iniviuals with a Dntal Visit, 1996, 2004, an 2010 1996 2004 2010 Dntal visit 42.9 43.6 41.3 No ntal visit 57.1 56.4 58.7 Total 100.0 100.0 100.0 Sour: GAO analysis of HHS ata. Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This tabl inlus only th noninstitutionaliz population. Trns in ntal visits by iniviuals with privat ntal ovrag largly xplain why th prntag of iniviuals with a ntal visit rmain rlativly unhang from 1996 to 2010. Spifially, ovr this prio th prntag of iniviuals with privat ntal ovrag who ha a ntal visit rmain th sam, at aroun 56 prnt (s tabl 4), an iniviuals with privat ovrag ma up a larg majority aroun 80 to 85 prnt of th population with ntal ovrag uring that tim prio. Th numbr of iniviuals without ntal ovrag who ha a ntal visit lin from 26 prnt, or 19 million iniviuals, in 1996 to 18 prnt, or 14 million iniviuals, in 2010. Tabl 4: Prntag of Iniviuals with a Dntal Visit, by Covrag Status, 1996, 2004, an 2010 1996 2004 2010 Privat 56.4 57.3 56.9 Miai 27.7 31.6 33.6 a Unknown 33.5 34.8 31.8 Non 25.8 21.7 18.0 Sour: GAO analysis of HHS ata. Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This tabl inlus only th noninstitutionaliz population with a ntal visit. For 2004 an 2010, Miai inlus hilrn nroll in th Stat Chilrn s Halth Insuran Program. a Iniviuals in th unknown atgory iniat that thy ha othr typs of publi mial ovrag, inluing stat or fral programs suh as Miar or vtran s bnfits. Ths programs might not hav inlu ntal ovrag, or might hav provi limit ntal ovrag to rtain iniviuals. For ths programs, th MEPS survy mthoology i not allow us to intify whih bnfiiaris atually ha ntal ovrag. Bnfiiaris in ths programs with a ntal laim pai by insuran uring th prio wr ount as having privat ovrag. For xampl, Miar Avantag nrolls who ha a laim pai by privat insuran wr ount in th privat insuran atgory. Miar bnfiiaris who i not hav a laim pai by insuran wr inlu in th unknown atgory baus thy might hav ha ntal ovrag suh as unr a Miar Avantag plan, but i not us thir ovrag uring th survy prio. Pag 15
Th prntag of iniviuals with Miai who ha a ntal visit inras from 1996 to 2010. This inras rflts an inras in th numbr of hilrn with Miai ovrag who ha a ntal visit, although ths hilrn still ha ntal visits at lowr rats than privatly insur hilrn (58 prnt). Th prntag of hilrn with Miai ntal ovrag with a ntal visit inras from 28 prnt, or 4 million hilrn, in 1996 to 37 prnt, or 11 million hilrn, in 2010. (S fig. 4.) Figur 4: Prntag of Chilrn, Ags 0-20 Yars, with Privat an Miai Dntal Covrag with a Dntal Visit, 1996, 2004, an 2010 Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This figur inlus th noninstitutionaliz population with a ntal visit. From 1996 to 2010, 72 prnt to 81 prnt of hilrn ags 0-20 yars ha privat or Miai ntal ovrag. For 2004 an 2010, Miai inlus hilrn nroll in th Stat Chilrn s Halth Insuran Program. Among iniviuals who rport having a ntal visit, thr was an inras in th prntag rporting that thy riv iagnosti an prvntiv srvis (for xampl, xams an lanings) an a ras in thos rporting that thy riv othr srvis, suh as rstorativ srvis (for xampl, fillings), from 1996 to 2010. Spifially, th prntag of visits for iagnosti an prvntiv srvis as a proportion Pag 16
of total ntal srvis inras (s fig. 5). Svnty-six prnt of ntal visits in 2010 onsist of iagnosti or prvntiv srvis (43 an 33 prnt, rsptivly). This is an inras from 69 prnt in 1996, whn iagnosti an prvntiv srvis ma up 40 an 29 prnt of srvis riv, rsptivly. Th prntag of visits for othr typs of srvis ras from 1996 to 2010. Spifially, rstorativ srvis suh as fillings ras slightly from 8 prnt to 6 prnt as a proportion of total ntal srvis riv in thos yars. Othr srvis that ras inlu prosthti an orthoonti srvis. Figur 5: Typs of Dntal Srvis as a Proportion of Total Srvis, 1996, 2004, an 2010 Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This figur inlus only th noninstitutionaliz population an prsnts th prntag of visits that wr for ah atgory of ntal prour. Th othr atgory inlus tratmnt for tmporomanibular joint an musl isorrs (jaw pain), boning, whitning or blahing, as wll as prioonti, prosthti, orthoonti, oral surgry, an noonti srvis. Pag 17
Avrag Paymnts for Dntal Srvis Inras from 1996 to 2010 Avrag annual paymnts ma on bhalf of or by iniviuals for ntal srvis inluing paymnts from othr payrs suh as insurrs an out-of-pokt paymnts inras from 1996 to 2010. 23 Avrag annual inflation-ajust ntal paymnts inras 26 prnt from $520 pr yar in 1996 to $653 pr yar in 2010 (s tabl 5). Th avrag annual paymnts ma inluing out-of-pokt paymnts an paymnts by othr payrs inras 24 prnt for th privatly insur, 39 prnt for iniviuals with Miai, an 38 prnt for thos without ntal ovrag. In aition, in 2010, avrag annual ntal paymnts (out of pokt an paymnts ma by othr payrs) for thos with privat ovrag wr narly twi as muh as th paymnts ma by an on bhalf of iniviuals with Miai ovrag. Tabl 5: Avrag Annual Dntal Paymnts for Iniviuals with a Dntal Visit, Ajust for Inflation, by Covrag Status, 1996, 2004, an 2010 1996 2004 2010 Avrag paymnt $520 $647 $653 Privat 580 713 719 Miai 269 356 373 a Unknown 623 630 Non 406 528 561 Sour: GAO analysis of HHS ata. Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This tabl inlus only th noninstitutionaliz population with a ntal visit. In MEPS, paymnts ar fin as th sum of paymnts for ar riv, inluing out-of-pokt paymnts an paymnts ma by privat insuran, Miai, Miar, an othr payrs. Paymnts wr ajust for inflation using th Consumr Pri Inx for All Urban Consumrs (CPI-U), 2010 ollars. Dashs iniat th sampl siz was too small for a rliabl stimat. For 2004 an 2010, Miai inlus hilrn nroll in th Stat Chilrn s Halth Insuran Program. a Iniviuals in th unknown atgory iniat that thy ha othr typs of publi mial ovrag, inluing stat or fral programs suh as Miar or vtran s bnfits. Ths programs might not hav inlu ntal ovrag, or might hav provi limit ntal ovrag to rtain iniviuals. For ths programs, th MEPS survy mthoology i not allow us to intify whih bnfiiaris atually ha ntal ovrag. Bnfiiaris in ths programs with a ntal laim pai by insuran uring th prio wr ount as having privat ovrag. For xampl, Miar Avantag nrolls who ha a laim pai by privat insuran wr ount in th privat insuran atgory. Miar bnfiiaris who i not hav a laim pai by insuran wr inlu in th unknown atgory baus thy might hav ha ntal ovrag suh as unr a Miar Avantag plan, but i not us thir ovrag uring th survy prio. 23 In MEPS, paymnts ar fin as th sum of paymnts for ar riv, inluing out-of-pokt paymnts an paymnts ma by privat insuran, Miai, an othr payrs. Thy o not inlu prmium osts. Paymnts wr ajust for inflation using th Consumr Pri Inx for All Urban Consumrs (CPI-U), 2010 ollars. Pag 18
Avrag annual paymnts for ntal srvis vari aross inom lvls. Paymnts ma by an on bhalf of iniviuals in th low-, an mil-inom groups inras staily from 1996 to 2010. Howvr, avrag annual paymnts ma by an on bhalf of iniviuals who wr poor inras from $373 in 1996 to $493 in 2004, an thn ras to $437 in 2010. 24 For low-inom iniviuals, that is, iniviuals with inoms at or blow 200 prnt but abov 100 prnt of th FPL, ntal paymnts ha th largst inras. Spifially, avrag annual ntal paymnts for th low-inom group inras from $393 in 1996 to $558 in 2010 (s fig. 6), about 42 prnt. Avrag annual ntal paymnts also inras for mil- an high-inom iniviuals 23 an 25 prnt, rsptivly. 24 Poor inlus iniviuals in familis with inom at or blow 100 prnt of th FPL. Pag 19
Figur 6: Avrag Annual Paymnts for Dntal Srvis for Iniviuals with a Dntal Visit, Ajust for Inflation, by Inom Lvl, 1996, 2004, an 2010 Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This figur inlus only th noninstitutionaliz population with a ntal visit. In MEPS, paymnts ar fin as th sum of paymnts for ar riv, inluing out-of-pokt paymnts an paymnts ma by privat insuran, Miai, Miar, an othr sours. Paymnts wr ajust for inflation using th Consumr Pri Inx for All Urban Consumrs (CPI-U), 2010 ollars. For this analysis, poor ar iniviuals in familis with inom at or blow 100 prnt of th fral povrty lvl (FPL). Th low inom group is iniviuals in familis with inoms at or blow 200 prnt of th FPL but abov 100 prnt of th FPL. Th mil-inom group is iniviuals in familis with inom at or blow 400 prnt of th FPL but abov 200 prnt of th FPL. Th highinom group is iniviuals in familis with inom gratr than 400 prnt of th FPL. Iniviuals out-of-pokt paymnts for ntal srvis, sparat from paymnts by othr payrs, whn ajust for inflation, gnrally inras from 1996 to 2010 (s fig. 7). Spifially, avrag annual out-of-pokt paymnts ma by iniviuals with privat ovrag inras 21 prnt from 1996 to 2010 from $242 to $294. Iniviuals with no ntal ovrag xprin th gratst inras in avrag annual out-of-pokt paymnts, from $392 to $518, a 32 prnt inras. For iniviuals with Miai ovrag, thir avrag annual Pag 20
out-of-pokt paymnts rmain rlativly unhang, $64 in 1996 an $59 in 2010. 25 Figur 7: Avrag Annual Out-of-Pokt Paymnts for Iniviuals with a Dntal Visit, 1996, 2004, an 2010 Nots: Data ar from Mial Expnitur Panl Survy (MEPS). This tabl inlus only th noninstitutionaliz population with a ntal visit. Paymnts wr ajust for inflation using th Consumr Pri Inx for All Urban Consumrs (CPI-U), 2010 ollars. For 2004 an 2010, Miai inlus hilrn nroll in th Stat Chilrn s Halth Insuran Program. Th out-of-pokt paymnts for iniviuals in th unknown group ar not rport in th figur baus of sampl siz onrns an high rlativ stanar rrors in th stimat. Rlativ stanar rror is th proportion of th stanar rror ivi by th stimat itslf. 25 Cost sharing in Miai for most srvis is limit to nominal amounts. S http://www.miai.gov/miai-chip-program-information/by-topis/cost- Sharing/Cost-Sharing.html (ass May 24, 2013). Pag 21
Fs Charg for Dntal Srvis Vari btwn an within Communitis Dntal fs harg by ntists an halth ntrs vari aross gographi aras an within ommunitis. For 24 ommon ntal prours, ntal fs harg by loal ntists vari signifiantly btwn th 18 ommunitis w xamin. In aition, ntal fs vari wily within ommunitis. Dntal fs also vari btwn loal ntists an halth ntrs that srv rsints of th sam ommunity, but all halth ntrs ar rquir to offr sliing f shuls for low-inom iniviuals. Dntal Fs Vari Wily btwn Communitis For 24 ommon ntal prours, mipoint ntal fs th amount whr half of fs harg wr highr an half wr lowr vari wily btwn th 18 ommunitis w xamin. 26 For xampl, mipoint ntal fs for an ault prophylaxis (ommonly all tth laning) in larg ommunitis rang from $76 in Nashvill, Tnnss, to $155 in Nw York, Nw York. In smallr ommunitis, mipoint fs rang from $59 in Jakson, Tnnss, to $88 in Frsno, California (s fig. 8). Similarly, mipoint fs harg for a hil prophylaxis rang from $55 to $105 in larg ommunitis an $48 to $71 in small ommunitis. Dntal fs, as with othr halth ar osts, vary by loation. (S tabls 10 to 27 in app. IV for mor information on th rang of ntal fs for othr ommon ntal prours in slt ommunitis.) 26 W analyz ntal insuran laims ata in nin stats orrsponing to th nin U.S. Cnsus ivisions. Using 2010 Cnsus ata, w slt two ommunitis in ah stat, on larg, bas on thir population an volum of ntal laims an on small bas on population. Our nin slt ommunity pairs, larg an small (with slt gozip), wr Phonix (850) an Flagstaff (860), Arizona; Los Angls (900) an Frsno (936), California; Miami (331) an Palm Coast (321), Floria; Chiago (606) an Champaign (618), Illinois; Boston (021) an Pittsfil (012), Massahustts; Minnapolis (554) an Mankato (560), Minnsota; Nw York (100) an Elmira (148), Nw York; Nashvill (372) an Jakson (382), Tnnss; an Dallas (752) an San Anglo (768), Txas. (S app. III for mor information on our sop an mthoology.) Pag 22
Figur 8: Mipoint Dntal Fs in 18 Communitis for Tth Claning (Ault an Chil), 2012 Not: Fs ar rport for Currnt Dntal Trminology (CDT) os D1110: Prophylaxis (Ault) an D1120: Prophylaxis (Chil). Th Amrian Dntal Assoiation sribs prophylaxis (ommonly all tth laning) as rmoval of plaqu, alulus, an stains from th tooth struturs in th prmannt an transitional ntition. Svral fators an ontribut to gographi variation in ntal fs, inluing loal wags an th ost of spa an quipmnt n to oprat a prati. Although w intifi no urrnt pr-rviw rsarh that stablish a orrlation btwn iniviual fators an th lvl of ntal fs, gographi variation in spning for mial srvis Pag 23
is wll oumnt. For xampl, th Congrssional Bugt Offi rport that a numbr of fators, inluing failitis, supplis, an wags, influn gographi variation in halth ar spning. 27 Th Cntrs for Miar & Miai Srvis (CMS), in stting Miar paymnt rats for halth ar srvis, stablishs a gographi prati ost inx for ah Miar paymnt loality to aount for variation in prati xpnss. CMS rport that it i not hav any omparabl prati ost inx for Miai ntal fs. Dntal Fs Vari Wily within Communitis Dntal laims ata also show signifiant iffrns within ommunitis for all 24 ommon ntal prours w xamin. Fs within th privat prati ntal stting ar afft by loal markt onitions an isions within th iniviually own pratis. FAIR Halth ntal laims ata show that within ommunitis th iffrn btwn mipoint an uppr-n fs was as high as 143 prnt for loaliz livry of antimirobial agnts. Uppr-n fs wr at last oubl th mipoint fs in at last on ommunity for 8 of th 24 ommon prours w xamin (s tabl 6). (S app. IV for information on all 24 prours in all 18 slt ommunitis.) 27 Congrssional Bugt Offi, Gographi Variation in Halth Car Spning, Pub. No. 2978 (Washington, D.C.: Fb. 2008). Pag 24
Tabl 6: Prours with th Largst Prntag Diffrn btwn Mipoint an Uppr-En Fs, 2012 Currnt Dntal Trminology (CDT) o Dsription Community (gozip) Mipoint f Uppr-n f Prntag iffrn D4381 Loaliz Dlivry of Antimirobial Los Angls, Calif. (900) $80 $194 143% Agnts via a Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D0120 Prioi Oral Evaluation Establish Miami, Fla. (331) 62 150 142 Patint D0230 Raiographs/Diagnosti Imaging: Nw York, N.Y. (100) 21 50 138 Intraoral Priapial Eah Aitional Film D1203 Topial Appliation of Fluori Chil Los Angls, Calif. 40 90 125 (900) D0274 Raiographs/Diagnosti Imaging: Miami, Fla. (331) 66 140 112 Bitwings Four Films D7140 Extration, Erupt Tooth or Expos Nw York, N.Y. (100) 290 600 107 Root (Elvation an/or Forps Rmoval) D0220 Raiographs/Diagnosti Imaging: Miami, Fla. (331) 25 50 100 Intraoral Priapial First Film D1204 Topial Appliation of Fluori Ault Los Angls, Calif. (900) 40 80 100 Sour: GAO analysis of FAIR Halth ata (as of January 2013). Amrian Dntal Assoiation (ADA) CDT finitions. Not: Mipoint fs ar th 50 th prntil an uppr-n fs ar th 95 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 95 prnt of rport fs fall blow th 95 th prntil). Dntal fs within ommunitis also vari wily for iagnosti prours. For th most ommon iagnosti prour, a prioi oral valuation of an stablish patint, th prntag iffrn btwn rport mipoint an uppr-n fs in larg ommunitis rang from 20 prnt to 142 prnt (s tabl 7). For xampl, in Miami, Floria, half of th fs harg by ntists for a prioi oral xamination of an stablish patint wr $62 or lss, but 5 prnt of fs harg for that prour wr $150 or mor, a 142 prnt iffrn. In small ommunitis, th prntag iffrn was lss, ranging from 17 prnt to 58 prnt. Pag 25
Tabl 7: Diffrns btwn Mipoint an Uppr-En Dntal Fs Charg for a Prioi Oral Evaluation of an Establish Patint, by Loal Dntists in 18 Communitis in Nin Stats, 2012 Community (gozip) Mipoint f Uppr-n f Prntag iffrn Larg ommunitis Miami, Fla. (331) $62 $150 142% Nw York, N.Y. (100) 80 152 90 Los Angls, Calif. (900) 63 110 75 Chiago, Ill. (606) 49 72 47 Phonix, Ariz. (850) 45 62 38 Nashvill, Tnn. (372) 42 57 36 Boston, Mass. (021) 49 65 33 Dallas, Tx. (752) 47 61 30 Minnapolis, Minn. (554) 50 60 20 Small ommunitis San Anglo, Tx. (768) $38 $60 58 Frsno, Calif. (936) 45 66 47 Jakson, Tnn. (382) 33 45 36 Palm Coast, Fla. (321) 36 49 36 Pittsfil, Mass. (012) 36 47 31 Elmira, N.Y. (148) 40 52 30 Champaign, Ill. (618) 40 50 25 Mankato, Minn. (560) 41 48 17 Flagstaff, Ariz. (860) 47 55 17 Sour: GAO analysis of FAIR Halth ata (as of January 2013). Amrian Dntal Assoiation (ADA) Currnt Dntal Trminology (CDT) finitions. Nots: Fs ar rport for CDT o D0120: Prioi Oral Evaluation (Establish Patint). ADA sribs this prour as an valuation prform on a patint of ror to trmin any hangs in th patint s ntal an mial halth status sin a prvious omprhnsiv or prioi valuation. This inlus an oral anr valuation an prioontal srning whr iniat, an may rquir intrprtation of information aquir through aitional iagnosti prours. Mipoint fs ar th 50 th prntil an uppr-n fs ar th 95 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 95 prnt of rport fs fall blow th 95 th prntil). Dntal fs within ommunitis also vari wily for rstorativ prours. For th most ommon rstorativ prour, a filling, th prntag iffrn btwn rport mipoint an uppr-n fs in larg ommunitis rang from 19 prnt to 67 prnt (s tabl 8). For xampl, in Phonix, Arizona, half of th fs harg by ntists for a filling wr $195 or lss, but 5 prnt of fs harg for that prour wr $325 or mor, a 67 prnt iffrn. In small Pag 26
ommunitis, th prntag iffrn was smallr, ranging from 13 prnt to 38 prnt. Tabl 8: Diffrns btwn Mipoint an Uppr-En Dntal Fs Charg for a Filling by Loal Dntists in 18 Communitis in Nin Stats, 2012 Community (gozip) Mipoint f Uppr-n f Prntag iffrn Larg ommunitis Phonix, Ariz. (850) $195 $325 67% Miami, Fla. (331) 200 320 60 Dallas, Tx. (752) 189 294 56 Los Angls, Calif. (900) 237 365 54 Nw York, N.Y. (100) 300 450 50 Nashvill, Tnn. (372) 200 287 44 Chiago, Ill. (606) 205 290 41 Boston, Mass. (021) 225 301 34 Minnapolis, Minn. (554) 244 290 19 Small ommunitis Frsno, Calif. (936) $208 $288 38 Pittsfil, Mass. (012) 179 242 35 San Anglo, Tx. (768) 180 242 34 Palm Coast, Fla. (321) 175 231 32 Flagstaff, Ariz. (860) 206 266 29 Elmira, N.Y. (148) 179 230 28 Mankato, Minn. (560) 194 243 25 Jakson, Tnn. (382) 160 191 19 Champaign, Ill. (618) 208 235 13 Sour: GAO analysis of FAIR Halth ata (as of January 2013). Amrian Dntal Assoiation (ADA) Currnt Dntal Trminology (CDT) finitions. Nots: Fs ar rport for CDT o D2392: Rsin-Bas Composit (Two Surfas, Postrior). Aoring to ADA, a rsin-bas omposit rfrs to a broa atgory of matrials inluing, but not limit to, omposits. May inlu bon omposit, light-ur omposit, t. Tooth prparation, ai thing, ahsivs (inluing rsin-boning agnts), linrs an bass an uring ar inlu as part of th rstoration. Mipoint fs ar th 50 th prntil an uppr-n fs ar th 95 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 95 prnt of rport fs fall blow th 95 th prntil). Pag 27
Dntal fs also vari btwn mipoint fs of loal ntists billing privat insurrs an th full fs of th frally fun halth ntrs that srv rsints of th sam ommunity. 28 In th 18 ommunitis w xamin, full ntal fs for a tooth xtration (th most ommon oral surgry prour) wr typially lowr at halth ntrs. For patints with inoms at or blow 100 prnt of th FPL, 10 halth ntrs offr a 100 prnt f isount an 8 halth ntrs ha fs ranging from $16 to $148 for xtrating a tooth (s tabl 9). Halth ntrs full fs whih fwr than 8 prnt of halth ntr patints pay wr oftn, but not always, lowr than th mipoint fs harg by loal ntists. In som ass, mipoint fs harg by loal ntists wr highr than halth ntr fs by a wi margin. For xampl, in Los Angls, th mipoint f harg by loal ntists for a tooth xtration was narly 3 tims th full f harg by a halth ntr srving rsints of th sam ommunity. In othr ass, full fs wr highr than thos of loal ntists. For xampl, in Frsno th halth ntr s full f was $177 for a tooth xtration ompar to th mipoint f harg by loal ntists of $142. (S app. IV for aitional information on loal ntist fs an halth ntr ntal fs.) 28 For familis that annot affor th prvailing ost of ntal ar, many obtain ntal ar from frally fun halth ntrs. Dntal srvis provi at halth ntrs ar availabl to all patints, rgarlss of thir ability to pay, an in gnral, halth ntrs must offr isount fs for familis with inoms at or blow 200 prnt of th FPL. Pag 28
Tabl 9: Dntal Fs Charg for a Tooth Extration by Loal Dntists an Halth Cntrs in 18 Communitis in Nin Stats, 2012 Community (gozip) Larg ommunitis Loal ntists mipoint f a Full f Halth ntrs b 100% of fral povrty lvl (FPL) Nw York, N.Y. (100) $290 $229 $36 Boston, Mass. (021) 175 157 0 Minnapolis, Minn. (554) 167 147 0 Miami, Fla. (331) 165 166 70 Los Angls, Calif. (900) 157 54 0 Dallas, Tx. (752) 152 159 16 Chiago, Ill. (606) 150 105 0 Phonix, Ariz. (850) 125 132 35 Nashvill, Tnn. (372) 125 70 0 Small ommunitis Champaign, Ill. (618) $159 $106 Pittsfil, Mass. (012) 153 145 0 Flagstaff, Ariz. (860) 149 179 90 Elmira, N.Y. (148) 143 122 0 Frsno, Calif. (936) 142 177 0 San Anglo, Tx. (768) 137 148 148 Palm Coast, Fla. (321) 135 134 0 Mankato, Minn. (560) 132 122 0 Jakson, Tnn. (382) 97 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Amrian Dntal Assoiation (ADA) Currnt Dntal Trminology (CDT) finitions. Not: Fs ar rport for CDT o D7140: Extration, Erupt Tooth or Expos Root (Elvation an/or Forps Rmoval). ADA sribs this prour as inluing routin rmoval of tooth strutur, minor smoothing of sokt bon, an losur, as nssary. a Mipoint fs ar th 50 th prntil rport for th prour in th gozip (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Gnrally, full fs ar thos harg by halth ntrs for patints with inoms abov 200 prnt of th FPL or thos with privat ovrag. Fs at 100 prnt of th FPL ar harg by halth ntrs for patints with inom at or lss than 100 prnt of th FPL. For patints at or blow 100 prnt of th FPL, th halth ntr ombins multipl srvis for a isount f. For xampl; patints woul pay a $40 opaymnt for a rstorativ appointmnt (on on or mor tth) whih oul inlu a tooth xtration. Halth ntr os not isount this prour. Halth ntr os not provi/subsiiz ntal ar for patints with inom at or abov 200 prnt of th FPL. f Pag 29
f Halth ntr os not oprat an in-hous ntal program, but ontrats for ntal ar with a loal ntist. Dntal patints with inom blow 200 prnt of th FPL ar harg a $20 opaymnt, an an riv up to $150 worth of ntal srvis pr yar. To assist halth ntrs in stablishing sliing f shuls for lowinom patints, HRSA offiials tol us that, as of Jun 2013, thy wr in th pross of prparing guian on isounting fs for all srvis provi as part of a halth ntr s sop of projt, inluing ntal srvis. In thnial ommnts on a raft of this rport, HHS not that th raft guian was in final laran, iniating that it was unrtain whthr th final poliy woul inlu guian on stablishing full-f shuls. Aoring to HHS, thr is oftn a signifiant unmt n for ntal ar srvis among patints srv by halth ntrs an as a rsult, halth ntrs an thir ommunity boars must mak isions about whthr to provi aitional ntal srvis to mt this n an vlop a f shul onsistnt with Halth Cntr Program rquirmnts. HHS ommnt that variation in fs an isounts rflt ah halth ntr's uniqu ommunity haratristis as wll as th boar's ision on how bst to balan thir ability to provi ths srvis against th unmt n in thir ommunity. Agny Commnts HHS rviw a raft of this rport an provi thnial ommnts, whih w inorporat as appropriat. As agr with your offi, unlss you publily announ th ontnts of this rport arlir, w plan no furthr istribution until 30 ays from th rport at. At that tim, w will sn opis to th Srtary of Halth an Human Srvis, intrst ongrssional ommitts, an othrs. In aition, th rport will b availabl at no harg on th GAO wbsit at http://www.gao.gov. Pag 30
If you or your staff hav any qustions about this rport, plas ontat m at (202) 512-7114 or iritanik@gao.gov. Contat points for our Offis of Congrssional Rlations an Publi Affairs may b foun on th last pag of this rport. GAO staff who ma major ontributions to this rport ar list in appnix V. Sinrly yours, Kathrin Iritani Dirtor, Halth Car Pag 31
Appnix I: National Expniturs Appnix I: National Dntal Expniturs To trmin national trns in U.S. ntal xpniturs, w obtain national xpnitur ata from HHS s Cntrs for Miar & Miai Srvis (CMS) Offi of th Atuary. In 2011, national xpniturs for ntal srvis in th Unit Stats wr about $108 billion, an inflationajust inras from $64 billion in 1996 (s fig. 9). Inflation-ajust xpniturs in th Unit Stats for ntal srvis ros an avrag of 3.6 prnt pr yar btwn 1996 an 2011 ranging from a 0.8 prnt ras in 2009 to a 6.9 prnt inras in 2002. Figur 9: National Expniturs for Dntal Srvis, Ajust for Inflation, 1996-2011 Nots: Data ar from th National Halth Expnitur Aounts. Th xpniturs in this figur hav bn ajust to 2011 ollars using th 2011 Gross Domsti Prout inx an onvrsion fators. Pag 32
Appnix II: Urban Rural Dntal Visit Appnix II: Urban an Rural Dntal Visit Rats Rats Iniviuals who liv in urban an rural aras rport ntal visits at iffrnt rats, with iniviuals in urban aras rporting highr rats of ntal visits. For xampl, in all ag groups, fwr iniviuals in rural aras rport having a ntal visit than iniviuals in urban aras (s fig. 10). Spifially, 34 prnt of iniviuals ags 65 an olr living in rural aras ha ntal visits in a yar, ompar with 45 prnt of thir ountrparts in urban aras, for 2008 through 2010. Th rats for hilrn wr similar: 35 prnt of hilrn 0 to 20 yars ol living in rural aras rport a ntal visit in a yar, ompar with 45 prnt of hilrn in urban aras. Figur 10: Prntag of Iniviuals with a Dntal Visit, by Ag an Loation, 2008-2010 Nots: Data ar from th Mial Expnitur Panl Survy (MEPS). This figur inlus th noninstitutionaliz population with a ntal visit uring th yar an rflts 3 yars of MEPS ata to nsur aquat sampl sizs for rporting. Th atgoris ar bas on th siz of th urbaniz population in ountis; th nonmtropolitan ountis ar sparat into thos that ar ajant to mtropolitan aras (suburban) an thos that ar mor rmot (rural). Pag 33
Appnix III: Sop Appnix III: Sop an Mthoology To provi information on th trns in ntal ovrag rats, us of ntal srvis, an paymnts by iniviuals an othr payrs for ntal srvis, w analyz nationwi ata from th Mial Expnitur Panl Survy (MEPS). W xamin an analyz ata from 3 yars: 1996, 2004, an 2010. W slt ths yars for our analysis baus 1996 was th first yar MEPS was aministr an 2010 was th most rnt yar for whih ata wr availabl, w inlu 2004 to provi thr points in tim for our analysis. MEPS is aministr by th Dpartmnt of Halth an Human Srvis (HHS) Agny for Halthar Rsarh an Quality (AHRQ) an is a nationally rprsntativ survy of th noninstitutionaliz population, inluing familis, mial provirs, an mployrs. MEPS ollts slf-rport information on iniviuals mographis, halth an insuran status, an us of mial srvis by stting an provir typ, as wll as xpnss an paymnts rlat to thos mial an ntal visits, among othr things. W analyz rsponss to MEPS qustions about typs of ntal insuran ovrag, numbr of ntal visits, typs of ntal prours riv, an paymnts ma rlat to thos visits. A ntal visit rfrs to ar by or visits to any typ of ntal ar provir, inluing gnral ntists, ntal hyginists, ntal thniians, ntal surgons, orthoontists, noontists, an prioontists. For this rport, w rfrr to all visits as ntal visits. To trmin whthr an iniviual ha privat ntal insuran ovrag, w xamin MEPS ata an not whthr th iniviual rport having ntal insuran or ha privat insuran pay on a ntal laim uring th yar. Thus, w onsir an iniviual to hav privat ntal ovrag if h or sh (1) rport having ntal insuran or (2) ha that insurr pay on a ntal laim. To intify ault Miai ovrag by stat, w us a list of stats provi by th Cntrs for Miar & Miai Srvis (CMS) for 2004 an 2010. For stats that wr intifi as having limit or mrgny only ntal ovrag, w i not onsir thos bnfits to b Miai ntal ovrag. Our analysis of ault Miai ovrag bas on th list from CMS rsult in only small iffrns from a Pag 34
Appnix III: Sop an Mthoology similar analysis onut by AHRQ for its Chartbook 17 publiation that xamins ntal ovrag an xpnss. 1 To atgoriz ntal prour os, w onsult with AHRQ an us th sam atgoris us by AHRQ for its Chartbook 17. For xampl, AHRQ pla various ntal prour os rlat to prvntiv ntal ar suh as tth laning an salant appliation in th prvntiv srvis atgory. In MEPS, xpnss ar fin as th sum of paymnts for ar riv, inluing out-of-pokt paymnts an paymnts ma by privat insuran, Miai, Miar, an othr sours. For this rport, w rfrr to MEPS xpnss as paymnts paymnts by insurrs or othr payrs as wll as out-of-pokt paymnts ma by iniviuals. To prsnt th ntal paymnts in onstant 2010 ollars, w us th Consumr Pri Inx for All Urban Consumrs (CPI-U) as th pri flator for both th aggrgat ntal paymnts an th out-of-pokt paymnts. To intify potntial iffrns in ntal srvi us an paymnts by mographi groups, w look at rsponss by ag group, inom lvl, an urban or rural ara. W xamin inom lvl in trms of th fral povrty lvl. To onut th urban an rural analysis, w assign iniviuals to on of thr groups bas on th ounty thy liv in ah ounty was signat urban, suburban, or rural bas on th Rural Urban Continuum Cos (RUCC). 2 W atgoriz thos iniviuals as follows: thos who liv in ountis signat 1, 2, or 3 in th RUCC wr urban; ountis signat 4, 6, or 8, suburban; an in ountis signat 5, 7, or 9, rural. In onuting th urban an rural analysis, to nsur aquat sampl sizs, w ombin MEPS ata for 2008, 2009, an 2010. This was th 1 Chartbook 17 xamin MEPS ata rlat to ntal ovrag, us an paymnts in 1996 an 2004. To alulat Miai ovrag for 1996, w us AHRQ s information us in th Chartbook. R.J. Manski an E. Brown, Dntal Us, Expnss, Privat Dntal Covrag, an Changs, 1996 an 2004, MEPS Chartbook No.17 (Rokvill, M.: Agny for Halthar Rsarh an Quality, 2007). S http://www.mps.ahrq.gov/mpswb/ata_fils/publiations/b17/b17.pf. 2 For this analysis, w us th 2003 RUCCs. This was th most rnt ata availabl at th tim of our stuy. Pag 35
Appnix III: Sop an Mthoology only analysis whr a ombination of yars was nssary. Dspit this ffort, small sampl sizs for som analyss limit th rliability of th rsults, an in thos ass, w i not rport thos analyss. To trmin th rliability of th MEPS ata, w rviw rlat oumntation, intrviw agny offiials, an intifi othr stuis that us MEPS to arss similar rsarh qustions to ompar th publish ata with our finings. W trmin that th MEPS ata wr suffiintly rliabl for th purposs of our rport. To trmin th xtnt to whih ntal fs vari btwn an within slt ommunitis, w analyz ntal insuran laims ata an ntal fs harg by slt halth ntrs in nin stats orrsponing to th nin U.S. Cnsus Burau ivisions. Using 2010 Cnsus ata, w slt two ommunitis in ah stat, on larg bas on population an volum of ntal laims an on small bas on population. Our nin slt ommunity pairs, larg an small (with slt gozips), wr Phonix (850) an Flagstaff (860), Arizona; Los Angls (900) an Frsno (936), California; Miami (331) an Palm Coast (321), Floria; Chiago (606) an Champaign (618), Illinois; Boston (021) an Pittsfil (012), Massahustts; Minnapolis (554) an Mankato (560), Minnsota; Nw York (100) an Elmira (148), Nw York; Nashvill (372) an Jakson (382), Tnnss; an Dallas (752) an San Anglo (768), Txas. To intify rprsntativ ntal fs in ah ommunity, w analyz (1) 2012 ntal insuran laims ata ompil by FAIR Halth, In., as of January 2013, 3 an (2) ntal f shuls from slt halth ntrs srving ths ommunitis. Bas on th FAIR Halth laims ata, w slt 24 of th most of ommonly bill ntal prours in six atgoris of th Amrian Dntal Assoiation s (ADA) Currnt Dntal Trminology (CDT) os: fiv iagnosti, fiv prvntiv, fiv rstorativ, thr noonti, thr prioonti, an thr oral surgry. 4 W onsult with aami ntal xprts an ADA offiials to onfirm that 3 Th FAIR Halth ata st ontain information on 579 Currnt Dntal Trminology (CDT) os in 491 gozips a gozip is an ara that shars th first thr igits of a postal zip o. S http://www.fairhalth.org/ for mor information about FAIR Halth an th ntal laims ata st. 4 Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th ADA as opyright ownr. Pag 36
Appnix III: Sop an Mthoology th CDT os w slt wr rprsntativ of ommon ntal prours. W also ompar our list of ommon ntal prours to ata from th ADA Survy of Dntal Fs. 5 W also obtain halth ntr ntal fs for ths 24 prours in our 18 slt ommunitis. Bas on a list of halth ntrs provi by HHS s Halth Rsours an Srvis Aministration (HRSA), w slt on halth ntr (th ntr that srv th most ntal patints) in ah ommunity. W obtain full-f an sliing f shuls from ah halth ntr, although som halth ntrs i not provi or bill sparatly for all 24 prours. Th 18 halth ntrs stui may not b rprsntativ of th mor than 1,200 halth ntrs support by HRSA. For ah slt ntal prour, w xtrat from th FAIR Halth ata st th mipoint ntal f (th 50 th prntil) an th uppr-n f (th 95 th prntil). A prntil iniats th prntag of rport fs that wr blow th stat amount; for xampl, 95 prnt of rport fs fall blow th 95 th prntil. Within ah ommunity, w slt on gozip (an ara that shars th first thr igits of a postal zip o) with th most ntal laims to rprsnt th ommunity. Baus gozip bounaris o not align with mtropolitan statistial ara signations, w slt on gozip (th on with th most ntal laims) to rprsnt ah larg an ah small mtropolitan ara. Larg mtropolitan aras an inlu multipl gozips. For xampl, th Los Angls/Long Bah mtropolitan ara inlus gozips 900 to 912 (xluing 909). To trmin th rliability of th FAIR Halth an halth ntr ata, w rviw rlat oumntation, intrviw agny offiials an aami xprts, an onut ata tsting for missing ata. W trmin that both th FAIR Halth an halth ntr ata wr suffiintly rliabl for th purposs of our rport. 5 Amrian Dntal Assoiation, 2011 Survy of Dntal Fs (Chiago, Ill.: Dmbr 2011). Pag 37
Appnix IV: Dntal Charg for Appnix IV: Dntal Fs Charg for Common Prours in 18 Communitis Common Dntal Prours in 18 Communitis This appnix prsnts information on loal ntist fs an halth ntr fs for 24 ommon ntal prours in th 18 ommunitis (by spifi gozips) w xamin (s tabls 10 to 27). Tabl 10: Dntal Fs Charg for Common Prours in Phonix, Arizona (850), 2012 Loal ntist f Halth ntr f CDT o Dsription a Mipoint b Uppr-n 100% FPL Full f Diagnosti D0120 Prioi Oral Evaluation Establish Patint $45 $62 $35 $42 D0150 Comprhnsiv Oral Evaluation Nw or Establish 75 95 35 72 Patint D0220 Raiographs/Diagnosti Imaging: Intraoral Priapial 25 35 24 24 First Film D0230 Raiographs/Diagnosti Imaging: Intraoral Priapial 20 29 20 20 Eah Aitional Film D0274 Raiographs/Diagnosti Imaging: Bitwings Four 53 71 35 52 Films Prvntiv D1110 Prophylaxis Ault 81 99 35 74 D1120 Prophylaxis Chil 63 77 35 56 D1203 Topial Appliation of Fluori Chil 30 40 30 30 D1204 Topial Appliation of Fluori Ault 30 40 32 32 D1351 Salant pr Tooth 46 56 35 46 Rstorativ D2330 Rsin-Bas Composit On Surfa, Antrior 141 190 35 128 D2391 Rsin-Bas Composit On Surfa, Postrior 155 219 35 144 D2392 Rsin-Bas Composit Two Surfas, Postrior 195 325 35 188 D2393 Rsin-Bas Composit Thr Surfas, Postrior 237 363 35 234 D2950 Cor Builup, Inluing Any Pins 230 310 35 224 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final 677 950 200 586 Rstoration) D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 789 1,000 300 686 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final Rstoration) 1,045 1,250 400 840 Pag 38
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Prioontis D4341 D4381 D4910 Oral surgry D7140 D7210 Prioontal Saling an Root Planing Four or Mor Tth pr Quarant Halth ntr f 100% FPL Full f 232 287 35 204 Loaliz Dlivry of Antimirobial Agnts via a Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport 45 104 Prioontal Maintnan 122 175 35 116 Extration, Erupt Tooth or Expos Root (Elvation an/or Forps Rmoval) Surgial Rmoval of Erupt Tooth Rquiring Rmoval of Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 400 490 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). 125 195 35 132 240 300 35 224 Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. 100 prnt fral povrty lvl (FPL) ar fs harg by th halth ntr for patints with inom at or lss than 100 prnt of th FPL. Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of FPL or for thos with privat ovrag. Halth ntr os not provi or bill sparatly for this prour. Pag 39
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 11: Dntal Fs Charg for Common Prours in Flagstaff, Arizona (860), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100 FPL Full f D0120 Prioi Oral Evaluation Establish Patint $47 $55 $26 $52 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 78 99 44 88 26 34 17 34 22 27 12 24 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 59 70 45 90 Prvntiv D1110 Prophylaxis Ault 85 99 47 94 D1120 Prophylaxis Chil 65 68 34 68 D1203 Topial Appliation of Fluori Chil 34 38 20 40 D1204 Topial Appliation of Fluori Ault 28 40 24 48 D1351 Salant pr Tooth 50 55 28.5 57 Rstorativ D2330 Rsin-Bas Composit On Surfa, Antrior 149 168 84.5 169 D2391 Rsin-Bas Composit On Surfa, Postrior 160 195 93.5 187 D2392 Rsin-Bas Composit Two Surfas, Postrior 206 266 131.5 263 D2393 Rsin-Bas Composit Thr Surfas, Postrior 255 328 163.5 327 D2950 Cor Builup, Inluing Any Pins 250 309 138.5 277 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final 700 825 400 800 Rstoration) D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 750 955 437.5 875 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final 1,100 1,169 578.5 1,157 Rstoration) Prioontis D4341 Prioontal Saling an Root Planing Four or Mor 236 305 172.5 345 Tth pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a 49 60 Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 130 159 69 138 Pag 40
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry Halth ntr f 100 FPL Full f D7140 Extration, Erupt Tooth or Expos Root (Elvation 149 185 89.5 179 an/or Forps Rmoval) D7210 Surgial Rmoval of Erupt Tooth Rquiring 250 319 142.5 285 Rmoval of Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 350 395 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. 100 prnt fral povrty lvl (FPL) ar fs harg by th halth ntr for patints with inom at or lss than 100 prnt of th FPL. Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Halth ntr os not provi or bill sparatly for this prour. Pag 41
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 12: Dntal Fs Charg for Common Prours in Los Angls, California (900), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $63 $110 $0 $150 D0150 D0220 D0230 D0274 Prvntiv Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 89 150 0 200 30 50 20 40 Raiographs/Diagnosti Imaging: Bitwings Four Films 70 100 D1110 Prophylaxis Ault 100 150 0 120 D1120 Prophylaxis Chil 85 120 0 90 D1203 Topial Appliation of Fluori Chil 40 90 0 54 D1204 Topial Appliation of Fluori Ault 40 80 0 18 D1351 Salant pr Tooth 66 102 0 66 Rstorativ D2330 Rsin-Bas Composit On Surfa, Antrior 163 290 0 165 D2391 Rsin-Bas Composit On Surfa, Postrior 185 300 0 117 D2392 Rsin-Bas Composit Two Surfas, Postrior 237 365 0 144 D2393 Rsin-Bas Composit Thr Surfas, Postrior 280 414 0 171 D2950 Cor Builup, Inluing Any Pins 250 390 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final Rstoration) 690 1,200 D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 800 1,400 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final 1,000 1,700 0 500 Rstoration) Prioontis D4341 Prioontal Saling an Root Planing Four or Mor 240 350 0 84 Tth pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a 80 194 Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 145 195 0 72 Pag 42
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry Halth ntr f 100% FPL Full f D7140 Extration, Erupt Tooth or Expos Root (Elvation 157 300 0 54 an/or Forps Rmoval) D7210 Surgial Rmoval of Erupt Tooth Rquiring 275 495 0 96 Rmoval of Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 450 754 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. For patints with inom at or blow 100 prnt of th fral povrty lvl (FPL), fs ar isount 100 prnt. Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Halth ntr os not provi or bill sparatly for this prour. Pag 43
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 13: Dntal Fs Charg for Common Prours in Frsno, California (936), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $45 $66 $0 $53 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 72 107 0 93 27 40 0 30 17 30 0 26 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 60 83 0 68 Prvntiv D1110 Prophylaxis Ault 88 108 0 95 D1120 Prophylaxis Chil 71 91 0 71 D1203 Topial Appliation of Fluori Chil 30 50 0 39 D1204 Topial Appliation of Fluori Ault 31 50 0 39 D1351 Salant pr Tooth 50 75 0 57 Rstorativ D2330 Rsin-Bas Composit On Surfa, Antrior 148 194 0 171 D2391 Rsin-Bas Composit On Surfa, Postrior 160 225 0 189 D2392 Rsin-Bas Composit Two Surfas, Postrior 208 288 0 246 D2393 Rsin-Bas Composit Thr Surfas, Postrior 248 364 0 303 D2950 Cor Builup, Inluing Any Pins 225 325 0 289 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final 650 895 0 785 Rstoration) D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 775 979 0 905 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final 1,013 1,218 0 1,095 Rstoration) Prioontis D4341 Prioontal Saling an Root Planing Four or Mor 225 311 0 269 Tth pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a 91 150 Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 138 173 0 147 Pag 44
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry Halth ntr f 100% FPL Full f D7140 Extration, Erupt Tooth or Expos Root (Elvation 142 214 0 188 an/or Forps Rmoval) D7210 Surgial Rmoval of Erupt Tooth Rquiring Rmoval 250 351 0 294 of Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 385 499 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. For patints with inom at or blow 100 prnt of th fral povrty lvl (FPL), fs ar isount 100 prnt an patints ar harg a $35 opaymnt (plus 30 prnt of outsi lab fs). Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Halth ntr os not provi or bill sparatly for this prour. Pag 45
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 14: Dntal Fs Charg for Common Prours in Miami, Floria (331), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $62 $150 $20 $49 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 85 150 30 85 25 50 10 28 22 50 10 24 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 66 140 20 62 Prvntiv D1110 Prophylaxis Ault 95 150 35 90 D1120 Prophylaxis Chil 75 120 25 65 D1203 Topial Appliation of Fluori Chil 32 60 10 35 D1204 Topial Appliation of Fluori Ault 49 85 10 36 D1351 Salant pr Tooth 47 80 20 54 Rstorativ D2330 Rsin-Bas Composit On Surfa, Antrior 154 250 55 160 D2391 Rsin-Bas Composit On Surfa, Postrior 170 270 60 175 D2392 Rsin-Bas Composit Two Surfas, Postrior 200 320 75 225 D2393 Rsin-Bas Composit Thr Surfas, Postrior 255 400 90 279 D2950 Cor Builup, Inluing Any Pins 250 400 100 264 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final 850 1,400 400 700 Rstoration) D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 935 1,545 500 814 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final 1,163 1,760 600 977 Rstoration) Prioontis D4341 Prioontal Saling an Root Planing Four or Mor 245 384 70 241 Tth pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a 60 125 Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 128 195 55 135 Pag 46
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry Halth ntr f 100% FPL Full f D7140 Extration, Erupt Tooth or Expos Root (Elvation 165 325 70 166 an/or Forps Rmoval) D7210 Surgial Rmoval of Erupt Tooth Rquiring Rmoval 275 500 110 273 of Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 460 750 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. 100 prnt fral povrty lvl (FPL) ar fs harg by th halth ntr for patints with inom at or lss than 100 prnt of th FPL. Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Halth ntr os not provi or bill sparatly for this prour. Pag 47
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 15: Dntal Fs Charg for Common Prours in Palm Coast, Floria (321), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $36 $49 $0 $52 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 65 88 0 84 20 28 0 26 13 24 0 22 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 46 62 0 56 Prvntiv D1110 Prophylaxis Ault 72 87 0 84 D1120 Prophylaxis Chil 57 65 0 60 D1203 Topial Appliation of Fluori Chil 34 36 D1204 D1351 Rstorativ Topial Appliation of Fluori Ault 25 37 Salant pr Tooth 45 58 0 42 D2330 Rsin-Bas Composit On Surfa, Antrior 120 175 0 130 D2391 Rsin-Bas Composit On Surfa, Postrior 140 191 0 152 D2392 Rsin-Bas Composit Two Surfas, Postrior 175 231 0 196 D2393 Rsin-Bas Composit Thr Surfas, Postrior 195 291 0 248 D2950 Cor Builup, Inluing Any Pins 210 283 0 264 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final 685 845 0 650 Rstoration) D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 795 990 0 768 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final Rstoration) 940 1,200 0 988 Prioontis D4341 Prioontal Saling an Root Planing Four or Mor 183 250 0 244 Tth pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a 59 95 Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 100 133 0 140 Pag 48
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry Halth ntr f 100% FPL Full f D7140 Extration, Erupt Tooth or Expos Root (Elvation 135 200 0 134 an/or Forps Rmoval) D7210 Surgial Rmoval of Erupt Tooth Rquiring Rmoval 219 299 0 248 of Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 436 515 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. For patints with inom at or blow 100 prnt of th fral povrty lvl (FPL), fs ar isount 100 prnt an patints ar harg a $45 opaymnt. Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Halth ntr os not provi or bill sparatly for this prour. Pag 49
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 16: Dntal Fs Charg for Common Prours in Chiago, Illinois (606), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $49 $72 $30 $35 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 75 114 30 50 25 40 30 19 20 35 30 19 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 60 83 30 50 Prvntiv D1110 Prophylaxis Ault 90 120 30 72 D1120 Prophylaxis Chil 65 87 30 53 D1203 Topial Appliation of Fluori Chil 35 51 30 28 D1204 Topial Appliation of Fluori Ault 30 50 30 28 D1351 Salant pr Tooth 52 72 30 39 Rstorativ D2330 Rsin-Bas Composit On Surfa, Antrior 150 225 30 99 D2391 Rsin-Bas Composit On Surfa, Postrior 160 235 30 110 D2392 Rsin-Bas Composit Two Surfas, Postrior 205 290 30 145 D2393 Rsin-Bas Composit Thr Surfas, Postrior 236 350 30 175 D2950 Cor Builup, Inluing Any Pins 250 367 30 195 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final 700 1,025 30 495 Rstoration) D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 800 1,200 30 590 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final Rstoration) 1,000 1,500 30 710 Prioontis D4341 Prioontal Saling an Root Planing Four or Mor 222 300 30 185 Tth pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a 40 83 Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 131 176 30 119 Pag 50
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry Halth ntr f 100% FPL Full f D7140 Extration, Erupt Tooth or Expos Root (Elvation 150 240 30 105 an/or Forps Rmoval) D7210 Surgial Rmoval of Erupt Tooth Rquiring Rmoval of 260 390 30 262 Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 500 661 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. Patints with inom at or blow 100 prnt of th fral povrty lvl (FPL) ar harg $30 pr visit plus $30 pr prour. Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Halth ntr os not provi or bill sparatly for this prour. Pag 51
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 17: Dntal Fs Charg for Common Prours in Champaign, Illinois (618), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $40 $50 $20 $28 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 77 87 40 55 26 31 20 21 26 16 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 59 70 43 Prvntiv D1110 Prophylaxis Ault 78 91 60 D1120 Prophylaxis Chil 61 67 45 D1203 Topial Appliation of Fluori Chil 31 38 27 D1204 Topial Appliation of Fluori Ault 31 39 28 D1351 Salant pr Tooth 51 57 40 Rstorativ D2330 Rsin-Bas Composit On Surfa, Antrior 133 163 40 98 D2391 Rsin-Bas Composit On Surfa, Postrior 152 180 40 109 D2392 Rsin-Bas Composit Two Surfas, Postrior 208 235 40 141 D2393 Rsin-Bas Composit Thr Surfas, Postrior 252 290 40 177 D2950 Cor Builup, Inluing Any Pins 271 281 40 175 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final Rstoration) D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final Rstoration) Prioontis D4341 Prioontal Saling an Root Planing Four or Mor Tth pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 726 795 517 836 895 449 1,005 1,025 549 246 294 196 69 104 Prioontal Maintnan 129 143 109 Pag 52
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry D7140 D7210 Extration, Erupt Tooth or Expos Root (Elvation an/or Forps Rmoval) Surgial Rmoval of Erupt Tooth Rquiring Rmoval of Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 471 525 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Halth ntr f 100% FPL Full f 159 190 106 258 301 209 Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. For patints with inom at or blow 100 prnt of th fral povrty lvl (FPL), fs ar pr visit: $20 for a D0120 with D0220 an possibly D0230; $40 for a D0150 with D0274; $40 for a hygin appointmnt, whih oul inlu D0120, D1110, D1204, D4341, an/or D4910 (if th patint is a hil not on Miai, th visit oul also inlu hil os with on or mor salants (D1351)); $40 for a rstorativ appointmnt, whih oul inlu on or mor tth an all of th os unr rstorativ an D7140 an D7210. Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Halth ntr os not provi or bill sparatly for this prour. Pag 53
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 18: Dntal Fs Charg for Common Prours in Boston, Massahustts (021), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $49 $65 0 $55 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 86 150 0 88 30 45 0 33 25 40 0 24 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 70 95 0 74 Prvntiv D1110 Prophylaxis Ault 100 131 0 100 D1120 Prophylaxis Chil 78 115 0 63 D1203 Topial Appliation of Fluori Chil 38 50 D1204 D1351 Rstorativ Topial Appliation of Fluori Ault 38 53 Salant pr Tooth 65 92 0 51 D2330 Rsin-Bas Composit On Surfa, Antrior 160 225 0 151 D2391 Rsin-Bas Composit On Surfa, Postrior 179 240 0 163 D2392 Rsin-Bas Composit Two Surfas, Postrior 225 301 0 212 D2393 Rsin-Bas Composit Thr Surfas, Postrior 275 370 0 267 D2950 Cor Builup, Inluing Any Pins 340 460 0 260 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final 850 1,225 0 675 Rstoration) D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 1,050 1,325 0 785 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final 1,350 1,610 0 940 Rstoration) Prioontis D4341 Prioontal Saling an Root Planing Four or Mor 251 345 0 234 Tth pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a 63 120 0 168 Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 140 184 0 128 Pag 54
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry Halth ntr f 100% FPL Full f D7140 Extration, Erupt Tooth or Expos Root (Elvation 175 237 0 157 an/or Forps Rmoval) D7210 Surgial Rmoval of Erupt Tooth Rquiring Rmoval 280 386 0 258 of Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 588 795 0 460 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. For patints with inom at or blow 100 prnt of th fral povrty lvl (FPL), fs ar isount 100 prnt an patints ar harg a $20 opaymnt. Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Halth ntr os not provi or bill sparatly for this prour. Pag 55
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 19: Dntal Fs Charg for Common Prours in Pittsfil, Massahustts (012), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $36 $47 $0 $38 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 68 103 0 51 25 32 0 24 22 30 0 20 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 58 76 0 54 Prvntiv D1110 Prophylaxis Ault 80 95 0 78 D1120 Prophylaxis Chil 56 73 0 56 D1203 Topial Appliation of Fluori Chil 27 39 0 31 D1204 Topial Appliation of Fluori Ault 27 30 0 31 D1351 Salant pr Tooth 49 54 0 46 Rstorativ D2330 Rsin-Bas Composit On Surfa, Antrior 130 163 0 125 D2391 Rsin-Bas Composit On Surfa, Postrior 135 181 0 145 D2392 Rsin-Bas Composit Two Surfas, Postrior 179 242 0 190 D2393 Rsin-Bas Composit Thr Surfas, Postrior 216 249 0 225 D2950 Cor Builup, Inluing Any Pins 265 309 0 230 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final 697 995 0 625 Rstoration) D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 875 1,140 0 735 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final 1,050 1,495 0 900 Rstoration) Prioontis D4341 Prioontal Saling an Root Planing Four or Mor 241 290 0 215 Tth pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a 45 87 Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 125 144 0 115 Pag 56
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry Halth ntr f 100% FPL Full f D7140 Extration, Erupt Tooth or Expos Root (Elvation 153 185 0 145 an/or Forps Rmoval) D7210 Surgial Rmoval of Erupt Tooth Rquiring 255 300 0 235 Rmoval of Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 499 499 0 415 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. Halth ntr offrs two lvls of isount fs: 100 prnt isount for patints with inom blow 200 prnt of th fral povrty lvl (FPL), an 80 prnt isount for patints with inom at 200 prnt to 400 prnt of th FPL. Full fs ar thos harg by th halth ntr for patints with inom abov 400 prnt of th FPL or for thos with privat ovrag. Halth ntr os not provi or bill sparatly for this prour. Pag 57
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 20: Dntal Fs Charg for Common Prours in Minnapolis, Minnsota (554), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $50 $60 $0 $43 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 77 99 0 75 29 36 0 25 25 34 0 21 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 60 69 0 56 Prvntiv D1110 Prophylaxis Ault 92 111 0 79 D1120 Prophylaxis Chil 65 72 0 59 D1203 Topial Appliation of Fluori Chil 42 48 0 32 D1204 Topial Appliation of Fluori Ault 38 48 0 32 D1351 Salant pr Tooth 53 62 0 47 Rstorativ D2330 Rsin-Bas Composit On Surfa, Antrior 155 186 0 140 D2391 Rsin-Bas Composit On Surfa, Postrior 170 200 0 153 D2392 Rsin-Bas Composit Two Surfas, Postrior 244 290 0 200 D2393 Rsin-Bas Composit Thr Surfas, Postrior 300 363 0 249 D2950 Cor Builup, Inluing Any Pins 275 340 0 240 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final 786 911 0 643 Rstoration) D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 917 1,068 0 745 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final Rstoration) 1,122 1,321 0 902 Prioontis D4341 Prioontal Saling an Root Planing Four or Mor 270 368 0 222 Tth pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a 37 60 0 91 Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 149 182 0 121 Pag 58
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry Halth ntr f 100% FPL Full f D7140 Extration, Erupt Tooth or Expos Root (Elvation 167 200 0 147 an/or Forps Rmoval) D7210 Surgial Rmoval of Erupt Tooth Rquiring Rmoval 328 385 0 243 of Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 545 607 0 428 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95th prntil. Halth ntr offrs thr lvls of isount fs: 100 prnt isount for patints with inom at or blow 100 prnt of th fral povrty lvl (FPL), 95 prnt isount for patints with inom at 101 prnt to 150 prnt of th FPL, an 80 prnt isount for patints with inom at 151 prnt to 200 prnt of th FPL. Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Pag 59
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 21: Dntal Fs Charg for Common Prours in Mankato, Minnsota (560), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $41 $48 $0 $35 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 63 81 0 63 25 33 0 20 23 27 0 20 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 52 62 0 48 Prvntiv D1110 Prophylaxis Ault 76 89 0 72 D1120 Prophylaxis Chil 52 62 0 45 D1203 Topial Appliation of Fluori Chil 33 40 0 31 D1204 Topial Appliation of Fluori Ault 36 40 0 31 D1351 Salant pr Tooth 47 50 0 37 Rstorativ D2330 Rsin-Bas Composit On Surfa, Antrior 129 149 0 114 D2391 Rsin-Bas Composit On Surfa, Postrior 140 173 0 134 D2392 Rsin-Bas Composit Two Surfas, Postrior 194 243 0 166 D2393 Rsin-Bas Composit Thr Surfas, Postrior 243 298 0 198 D2950 Cor Builup, Inluing Any Pins 217 264 0 201 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final 600 787 0 499 Rstoration) D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 725 987 0 634 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final Rstoration) 899 1,207 0 768 Prioontis D4341 Prioontal Saling an Root Planing Four or Mor Tth 239 327 0 256 pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a Controll 39 48 0 64 Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 128 145 0 114 Pag 60
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry Halth ntr f 100% FPL Full f D7140 Extration, Erupt Tooth or Expos Root (Elvation 132 175 0 122 an/or Forps Rmoval) D7210 Surgial Rmoval of Erupt Tooth Rquiring Rmoval of 242 273 0 193 Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 469 486 0 371 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. For patints with inom at or blow 100 prnt of th fral povrty lvl (FPL), fs ar isount 100 prnt, but ths patints ar harg a opaymnt of $25 for prvntiv srvis or $40 for rstorativ or major ntal (nonlab srvis), fs ar 50 prnt of hargs for major ntal (lab srvis). Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Pag 61
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 22: Dntal Fs Charg for Common Prours in Nw York, Nw York (100), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $80 $152 $23 $68 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 123 200 46 220 29 50 11 36 21 50 6 30 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 80 140 23 80 Prvntiv D1110 Prophylaxis Ault 155 215 46 117 D1120 Prophylaxis Chil 105 160 34 85 D1203 Topial Appliation of Fluori Chil 55 100 11 47 D1204 Topial Appliation of Fluori Ault 70 125 11 51 D1351 Salant pr Tooth 90 125 34 68 Rstorativ D2330 Rsin-Bas Composit On Surfa, Antrior 225 400 46 198 D2391 Rsin-Bas Composit On Surfa, Postrior 247 375 44 229 D2392 Rsin-Bas Composit Two Surfas, Postrior 300 450 67 292 D2393 Rsin-Bas Composit Thr Surfas, Postrior 350 500 85 365 D2950 Cor Builup, Inluing Any Pins 350 600 75 355 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final 1,000 1,900 200 891 Rstoration) D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 1,150 1,950 240 1,038 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final Rstoration) 1,400 2,200 325 1,236 Prioontis D4341 Prioontal Saling an Root Planing Four or Mor 250 420 46 320 Tth pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a Controll 75 180 130 247 Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 195 295 46 179 Pag 62
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry Halth ntr f 100% FPL Full f D7140 Extration, Erupt Tooth or Expos Root (Elvation 290 600 36 229 an/or Forps Rmoval) D7210 Surgial Rmoval of Erupt Tooth Rquiring Rmoval of 400 750 72 357 Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 650 1,050 240 639 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. 100 prnt fral povrty lvl (FPL) ar fs harg by th halth ntr for patints with inom at or blow 100 prnt of th FPL. Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Pag 63
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 23: Dntal Fs Charg for Common Prours in Elmira, Nw York (148), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $40 $52 $0 $28 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 68 106 0 48 25 33 0 18 14 26 0 15 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 57 77 0 59 Prvntiv D1110 Prophylaxis Ault 77 95 0 69 D1120 Prophylaxis Chil 54 70 0 52 D1203 Topial Appliation of Fluori Chil 30 35 0 21 D1204 Topial Appliation of Fluori Ault 30 40 0 30 D1351 Salant pr Tooth 50 54 0 35 Rstorativ D2330 Rsin-Bas Composit On Surfa, Antrior 129 161 0 92 D2391 Rsin-Bas Composit On Surfa, Postrior 145 181 0 132 D2392 Rsin-Bas Composit Two Surfas, Postrior 179 230 0 166 D2393 Rsin-Bas Composit Thr Surfas, Postrior 220 315 0 193 D2950 Cor Builup, Inluing Any Pins 250 350 0 125 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final Rstoration) 650 950 0 559 D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 751 1,050 0 850 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final Rstoration) 1,000 1,150 0 1,044 Prioontis D4341 Prioontal Saling an Root Planing Four or Mor 224 260 0 137 Tth pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a 75 81 Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 90 138 0 104 Pag 64
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry Halth ntr f 100% FPL Full f D7140 Extration, Erupt Tooth or Expos Root (Elvation 143 180 0 122 an/or Forps Rmoval) D7210 Surgial Rmoval of Erupt Tooth Rquiring Rmoval 265 325 0 214 of Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 460 546 0 365 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. For patints with inom at or blow 100 prnt of th fral povrty lvl (FPL), halth ntr provis a 100 prnt isount an hargs a $10 opaymnt (waiv at shool-bas halth ntrs). Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Halth ntr os not provi or bill sparatly for this prour. Pag 65
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 24: Dntal Fs Charg for Common Prours in Nashvill, Tnnss (372), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $42 $57 $0 $35 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 74 105 0 45 26 39 0 15 22 35 0 12 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 57 75 0 34 Prvntiv D1110 Prophylaxis Ault 76 98 0 45 D1120 Prophylaxis Chil 55 75 0 50 D1203 Topial Appliation of Fluori Chil 29 40 0 21 D1204 Topial Appliation of Fluori Ault 26 41 0 20 D1351 Salant pr Tooth 42 60 0 35 Rstorativ D2330 Rsin-Bas Composit On Surfa, Antrior 140 176 0 75 D2391 Rsin-Bas Composit On Surfa, Postrior 155 196 0 125 D2392 Rsin-Bas Composit Two Surfas, Postrior 200 287 0 150 D2393 Rsin-Bas Composit Thr Surfas, Postrior 245 350 0 160 D2950 Cor Builup, Inluing Any Pins 242 310 0 250 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final 794 1,175 0 355 Rstoration) D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 991 1,275 0 425 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final Rstoration) 1,136 1,395 0 519 Prioontis D4341 Prioontal Saling an Root Planing Four or Mor 215 266 0 600 Tth pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a 37 43 Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 122 150 Pag 66
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry Halth ntr f 100% FPL Full f D7140 Extration, Erupt Tooth or Expos Root (Elvation 125 201 0 70 an/or Forps Rmoval) D7210 Surgial Rmoval of Erupt Tooth Rquiring Rmoval of 245 319 0 133 Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 447 475 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. For patints with inom at or blow 100 prnt of th fral povrty lvl (FPL), fs ar isount 100 prnt an patints ar harg a $25 opaymnt. Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Halth ntr os not provi or bill sparatly for this prour. Pag 67
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 25: Dntal Fs Charg for Common Prours in Jakson, Tnnss (382), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti D0120 Prioi Oral Evaluation Establish Patint $33 $45 D0150 D0220 D0230 D0274 Prvntiv Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 53 71 20 28 18 25 Raiographs/Diagnosti Imaging: Bitwings Four Films 50 62 D1110 Prophylaxis Ault 59 71 D1120 D1203 D1204 D1351 Rstorativ Prophylaxis Chil 48 55 Topial Appliation of Fluori Chil 24 30 Topial Appliation of Fluori Ault 24 30 Salant pr Tooth 43 48 D2330 Rsin-Bas Composit On Surfa, Antrior 102 137 D2391 D2392 D2393 D2950 Enoontis Rsin-Bas Composit On Surfa, Postrior 125 150 Rsin-Bas Composit Two Surfas, Postrior 160 191 Rsin-Bas Composit Thr Surfas, Postrior 190 245 Cor Builup, Inluing Any Pins 175 213 D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final Rstoration) 567 700 D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 635 840 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final Rstoration) 801 1,044 Prioontis D4341 Prioontal Saling an Root Planing Four or Mor Tth 175 211 pr Quarant D4381 D4910 Loaliz Dlivry of Antimirobial Agnts via a Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport 58 Insuffiint ata Prioontal Maintnan 98 127 Halth ntr f 100% FPL Full f Pag 68
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry D7140 D7210 D7240 Extration, Erupt Tooth or Expos Root (Elvation an/or Forps Rmoval) 97 138 Surgial Rmoval of Erupt Tooth Rquiring Rmoval of 200 250 Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat Rmoval of Impat Tooth Compltly Bony 365 425 Halth ntr f 100% FPL Full f Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. Halth ntr os not oprat an in-hous ntal program, but ontrats for ntal ar with a loal ntist. Dntal patints with inom blow 200 prnt of th fral povrty lvl (FPL) ar harg a $20 opaymnt an an riv up to $150 worth of ntal srvis pr yar. Halth ntr os not provi or subsiiz ntal ar for patints with inom at or abov 200 prnt of th FPL. Pag 69
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 26: Dntal Fs Charg for Common Prours in Dallas, Txas (752), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $47 $61 $4.6 $46 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 78 107 8 80 23 34 2.7 27 17 26 2.2 22 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 59 79 6 60 Prvntiv D1110 Prophylaxis Ault 89 110 8.5 85 D1120 Prophylaxis Chil 63 78 6.4 64 D1203 Topial Appliation of Fluori Chil 32 38 3.5 35 D1204 Topial Appliation of Fluori Ault 31 39 D1351 Rstorativ Salant pr Tooth 50 65 5 50 D2330 Rsin-Bas Composit On Surfa, Antrior 154 220 15 150 D2391 Rsin-Bas Composit On Surfa, Postrior 146 218 16.7 167 D2392 Rsin-Bas Composit Two Surfas, Postrior 189 294 21.7 217 D2393 Rsin-Bas Composit Thr Surfas, Postrior 261 344 26.8 268 D2950 Cor Builup, Inluing Any Pins 243 313 Enoontis D3310 Enoonti Thrapy, Antrior Tooth (Exluing Final 695 1,250 69.4 694 Rstoration) D3320 Enoonti Thrapy, Biuspi Tooth (Exluing Final 815 1,327 80 800 Rstoration) D3330 Enoonti Thrapy, Molar (Exluing Final Rstoration) 1,025 1,677 60 600 Prioontis D4341 Prioontal Saling an Root Planing Four or Mor 245 301 24.1 241 Tth pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a 60 91 Controll Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 130 166 Pag 70
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry Halth ntr f 100% FPL Full f D7140 Extration, Erupt Tooth or Expos Root (Elvation 152 245 15.9 159 an/or Forps Rmoval) D7210 Surgial Rmoval of Erupt Tooth Rquiring Rmoval 265 355 25.7 257 of Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 463 564 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. For patints with inom at or blow 100 prnt of th fral povrty lvl (FPL), fs ar isount 90 prnt an patints ar harg a $25 opaymnt. Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Halth ntr os not provi or bill sparatly for this prour. Pag 71
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Tabl 27: Dntal Fs Charg for Common Prours in San Anglo, Txas (768), 2012 Loal ntist f a b CDT o Dsription Mipoint Uppr-n Diagnosti Halth ntr f 100% FPL Full f D0120 Prioi Oral Evaluation Establish Patint $38 $60 $15 $74 D0150 D0220 D0230 Comprhnsiv Oral Evaluation Nw or Establish Patint Raiographs/Diagnosti Imaging: Intraoral Priapial First Film Raiographs/Diagnosti Imaging: Intraoral Priapial Eah Aitional Film 65 91 18 90 22 30 6 32 18 25 6 29 D0274 Raiographs/Diagnosti Imaging: Bitwings Four Films 51 65 14 68 Prvntiv D1110 Prophylaxis Ault 75 96 21 105 D1120 Prophylaxis Chil 55 72 17 85 D1203 Topial Appliation of Fluori Chil 30 40 8 38 D1204 Topial Appliation of Fluori Ault 25 40 8 38 D1351 Salant pr Tooth 48 60 9 47 Rstorativ D2330 Rsin-Bas Composit On Surfa, Antrior 126 180 28 140 D2391 Rsin-Bas Composit On Surfa, Postrior 139 193 31 155 D2392 Rsin-Bas Composit Two Surfas, Postrior 180 242 40 200 D2393 Rsin-Bas Composit Thr Surfas, Postrior 228 300 48 240 D2950 Cor Builup, Inluing Any Pins 225 300 23 113 Enoontis D3310 D3320 Enoonti Thrapy, Antrior Tooth (Exluing Final Rstoration) Enoonti Thrapy, Biuspi Tooth (Exluing Final Rstoration) 645 850 490 490 715 950 580 580 D3330 Enoonti Thrapy, Molar (Exluing Final Rstoration) 948 1,150 Prioontis D4341 Prioontal Saling an Root Planing Four or Mor Tth 204 275 100 100 pr Quarant D4381 Loaliz Dlivry of Antimirobial Agnts via a Controll 63 80 f f Rlas Vhil Into Disas Crviular Tissu, pr Tooth, by Rport D4910 Prioontal Maintnan 112 158 120 120 f f Pag 72
Appnix IV: Dntal Fs Charg for Common Dntal Prours in 18 Communitis Loal ntist f a b CDT o Dsription Mipoint Uppr-n Oral surgry D7140 D7210 Extration, Erupt Tooth or Expos Root (Elvation an/or Forps Rmoval) Surgial Rmoval of Erupt Tooth Rquiring Rmoval of Bon an/or Stioning of Tooth, an Inluing Elvation of th Muoprlostal Flap if Iniat D7240 Rmoval of Impat Tooth Compltly Bony 390 390 Sour: GAO analysis of FAIR Halth an halth ntr ata (as of January 2013). Halth ntr f 100% FPL Full f 137 187 148 148 227 322 257 257 Not: Currnt Dntal Trminology (CDT) Cos on Dntal Prours an Nomnlatur ar th intlltual proprty of th Amrian Dntal Assoiation (ADA) as opyright ownr. a Mipoint fs ar th 50 th prntil (prntils iniat th prntag of rport fs that ar blow th stat amount; for xampl, 50 prnt of rport fs fall blow th 50 th prntil). b Uppr-n fs ar th 95 th prntil. 100 prnt fral povrty lvl (FPL) ar fs harg by th halth ntr for patints with inom at or blow 100 prnt of th FPL. Full fs ar thos harg by th halth ntr for patints with inom abov 200 prnt of th FPL or for thos with privat ovrag. Halth ntr os not isount this srvi. f Halth ntr os not provi or bill sparatly for this prour. f f Pag 73
Appnix V: GAO an Staff Appnix V: GAO Contat an Staff Aknowlgmnts Aknowlgmnts GAO Contat Staff Aknowlgmnts Kathrin Iritani, (202) 512-7114, or iritanik@gao.gov In aition to th iniviual nam abov, Kim Yaman, Assistant Dirtor; Gorg Bogart; Carolyn Fitzgral; Molli Hrtl; Elizabth Morrison; an Trry Saiki ma ky ontributions to this rport. Pag 74
Rlat GAO Rlat GAO Prouts Oral Halth: Efforts Unr Way to Improv Chilrn s Ass to Dntal Srvis, but Sustain Attntion N to Arss Ongoing Conrns. GAO-11-96. Washington, D.C.: Novmbr 30, 2010. Miai: Stat an Fral Ations Hav Bn Takn to Improv Chilrn s Ass to Dntal Srvis, but Mor Can B Don. GAO-10-112T. Washington, D.C.: Otobr 7, 2009. Miai: Stat an Fral Ations Hav Bn Takn to Improv Chilrn s Ass to Dntal Srvis, but Gaps Rmain. GAO-09-723. Washington, D.C.: Sptmbr 30, 2009. Miai: Extnt of Dntal Disas in Chilrn Has Not Dras, an Millions Ar Estimat to Hav Untrat Tooth Day. GAO-08-1121. Washington, D.C.: Sptmbr 23, 2008. Halth Rsours an Srvis Aministration: Many Unrsrv Aras Lak a Halth Cntr Sit, an th Halth Cntr Program Ns Mor Ovrsight. GAO-08-723. Washington, D.C.: August 8, 2008. Miai: Conrns Rmain about Suffiiny of Data for Ovrsight of Chilrn s Dntal Srvis. GAO-07-826T. Washington, D.C.: May 2, 2007. Oral Halth: Fators Contributing to Low Us of Dntal Srvis by Low- Inom Populations. GAO/HEHS-00-149. Washington, D.C.: Sptmbr 11, 2000. Oral Halth: Dntal Disas Is a Chroni Problm Among Low-Inom Populations. GAO/HEHS-00-72. Washington, D.C.: April 12, 2000. (291072) Pag 75
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