| REPAIRS TO PROSTHETICS |
 |
|
|
ADA
Code |
Procedure |
Member
Pays |
| 5510 |
Repair broken complete denture base |
$20 + LAB |
 |
| 5520 |
Replace missing or broken teeth -
complete denture (each tooth) |
20 + LAB |
|
| 5610 |
Repair resin denture base |
20 + LAB |
|
| 5630 |
Repair or replace broken clasp |
20 + LAB |
|
| 5640 |
Replace broken teeth - per tooth |
20 + LAB |
|
| 5650 |
Add tooth to existing partial denture |
35 + LAB |
|
| 5730 |
Reline complete maxillary denture (chairside) |
55.00 |
|
| 5731 |
Reline complete mandibular denture (chairside) |
55.00 |
|
| 5740 |
Reline maxillary partial denture (chairside) |
55.00 |
|
| 5741 |
Reline mandibular partial denture (chairside) |
55.00 |
|
| 5750 |
Reline complete maxillary denture
(laboratory) |
40 + LAB |
|
| 5751 |
Reline complete mandibular denture
(laboratory) |
40 + LAB |
|
| 5760 |
Reline maxillary partial denture
(laboratory) |
40 + LAB |
|
| 5761 |
Reline mandibular partial denture
(laboratory) |
40 + LAB |
|
| 5850 |
Tissue conditioning - maxillary |
35.00 |
|
| 5851 |
Tissue conditioning - mandibular |
35.00 |
|
| |
*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
- Not all participating dentists perform all listed procedures,
including amalgams. Please consult your dentist prior to treatment for availability of services.
- Unlisted procedures are at the dentist's usual fee less 25%.
- 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%. |
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