Advantage AVF-1 Schedule of Benefits

Prosthetics (Dentures) Schedule

Diagnostic X-Rays and Tests Preventive Care Restorative Services (Fillings) Other Restorative Services Crowns and Bridges

Endodontics Periodontics (Gum Treatment) Prosthetics (Dentures) Extractions & Oral Surgery Orthodontics (Adults or Children) Miscellaneous Services

Limitations and Exclusions

ADA CODE		Procedure		Member Pays
		REMOVABLE PARTIAL AND COMPLETE DENTURES
		(Limit replacement to every 5 years)
D5110		COMPLETE DENTURE-UPPER		$498
D5120		COMPLETE DENTURE-LOWER		$498
D5130		IMMEDIATE DENTURE-UPPER		$543
D5140		IMMEDIATE DENTURE-LOWER		$543
D5211		UPPER PARTIAL-RESIN BASE with CONVENTIONAL CLASPS - RESTS &TEETH		$420
D5212		LOWER PARTIAL-RESIN BASE with CONVENTIONAL CLASPS - RESTS &TEETH		$488
D5213		UPPER PARTIAL-CAST METAL RESIN BASE with CONVENTIONAL CLASPS		$550
D5214		LOWER PARTIAL-CAST METAL RESIN BASE with CONVENTIONAL CLASPS		$550
D5410		ADJUST COMPLETE DENTURE-UPPER		$27
D5411		ADJUST COMPLETE DENTURE-LOWER		$27
D5421		ADJUST PARTIAL DENTURE-UPPER		$27
D5422		ADJUST PARTIAL DENTURE-LOWER		$27
		PROSTHETIC REPAIRS
D5510		REPAIR BROKEN COMPLETE DENTURE BASE		$55
D5520		REPLACE MISSING/BROKEN TOOTH - COMPLETE DENTURE-EA TOOTH		$46
D5610		REPAIR RESIN DENTURE BASE		$59
D5620		REPAIR CAST FRAMEWORK		$64
D5630		REPAIR OR REPLACE BROKEN CLASP		$77
D5640		REPLACE BROKEN TEETH-PER TOOTH		$50
D5650		ADDITIONAL TOOTH TO EXISTING PARTIAL DENTURE		$68
D5660		ADD CLASP TO EXISTING PARTIAL DENTURE		$82
D5710		REBASE COMPLETE UPPER DENTURE		$202
D5711		REBASE COMPLETE LOWER DENTURE		$193
D5720		REBASE UPPER PARTIAL DENTURE		$191
D5721		REBASE LOWER PARTIAL DENTURE		$191
D5730		RELINE COMPLETE UPPER DENTURE - CHAIRSIDE		$114
D5731		RELINE COMPLETE LOWER DENTURE - CHAIRSIDE		$114
D5740		RELINE UPPER PARTIAL DENTURE - CHAIRSIDE		$105
D5741		RELINE LOWER PARTIAL DENTURE - CHAIRSIDE		$105
D5750		RELINE COMPLETE UPPER DENTURE (LAB)		$152
D5751		RELINE COMPLETE LOWER DENTURE (LAB)		$152
D5760		RELINE UPPER PARTIAL DENTURE (LAB)		$150
D5761		RELINE LOWER PARTIAL DENTURE (LAB)		$150
D5850		TISSUE CONDITIONING, MAXILLARY		$48
D5851		TISSUE CONDITIONING, MANDIBULAR		$48

Note:
All procedures listed might not be performed by the Participating General Dentist you select. The co - payments shown apply to those Participating General Dentists who do perform those services. Therefore, you are encouraged to discuss the availability of the scheduled services with your Participating General Dentist. Procedures not listed on this schedule of benefits, that are performed by the Participating General Dentist, will be charged at that Participating General Dentist's usual and customary fee less 20%.

Specialist Services
Should you need a specialist (i.e. Endodontist, Oral Surgeon, Orthodontist, Periodontist, Prosthodontist, Pediatric Dentist), you may be referred by your Participating General Dentist. Co - payment percentage amounts are applicable when treatment is performed by a Participating Specialist. Procedures not listed on this schedule of benefits, that are performed by a Participating Specialist, will be charged at that Participating Specialist's usual and customary fee less 20%.