Charlotte County Public Schools


 

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CS150 Schedule1

1Select a service below
 
SERVICES
bulletAppointments
bulletDiagnostics
bulletPreventive Care
bulletRestorative
bulletResin Restoration
bulletCrown & Bridge
bulletEndodontics
bulletPeriodontics
bulletProsthodontics
bulletRepairs to Prosthetics
bulletProsthodontics (Fixed)
bulletExtractions
bulletOrthodontics
bulletAdjunctive General Service
 
bulletLimitations and Exclusions
 
CROWN & BRIDGE
ADA
Code
Procedure Member
Pays
2740 Crown - porcelain/ceramic substrate $280 + LAB
2750* Crown - porcelain fused to high noble metal 280.00
2751 Crown - porcelain fused to predominantly base metal 280.00
2752* Crown - porcelain fused to noble metal 280.00
2790* Crown - full cast high noble metal 280.00
2791 Crown - full cast predominantly base metal 280.00
2792* Crown - full cast noble metal 280.00
2910 Recement inlay 15.00
2920 Recement crown 15.00
2930 Prefabricated stainless steel crown - primary tooth 75.00
2950 Core buildup, including any pins 45.00
2951 Pin retention - per tooth 15.00
2952 Cast post and core in addition to crown 90 + LAB
2953 Each additional cast post - same tooth 90 + LAB
2954 Prefabricated post and core in addition to crown 90.00
2962 Labial veneer (porcelain laminate) - laboratory 280 + LAB
 
*The above co-payments do not include the additional cost of precious (high noble) and semi-precious (noble) metal.

The additional cost of precious metal shall not exceed $125 per unit and $75 per unit for semi-precious metal.
 
Note
  1. Not all participating dentists perform all listed procedures, including amalgams. Please consult your dentist prior to treatment for availability of services.
  2. Unlisted procedures are at the dentist's usual fee less 25%.
  3. When crown and/or bridgework exceeds six units in the same treatment plan, the patient may be charged an additional 50.00 per unit.
 
Specialist Services
Should you need a specialist, (i.e., Endodontist, Oral Surgeon, Periodontist, Pediatric Dentist), you may be referred by your Participating General Dentist, or you may refer yourself to any Participating Specialist. Co-payment amounts are applicable when treatment is performed by Participating Specialists. Benefits for
procedures not listed on the schedule, that are performed by a Participating Specialist, are available at the Participating Specialist's usual and customary fee less 25%.
 

 

 

Current Dental Terminology © 2004 American Dental Association. All rights reserved