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CS150 Schedule1
| 1Select a service below |
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| SERVICES |
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| PROSTHODONTICS |
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ADA
Code |
Procedure |
Member
Pays |
| 5110 |
Complete denture - maxillary |
$300 + LAB |
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| 5120 |
Complete denture - mandibular |
300 + LAB |
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| 5130 |
Immediate denture - maxillary |
300 + LAB |
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| 5140 |
Immediate denture - mandibular |
300 + LAB |
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| 5211 |
Maxillary partial denture - resin base |
300 + LAB |
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| 5212 |
Mandibular partial denture - resin base |
300 + LAB |
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| 5213 |
Maxillary partial denture - cast metal
framework, resin denture bases |
300 + LAB |
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| 5214 |
Mandibular partial denture - cast metal
framework,
resin denture bases |
300 + LAB |
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| 5410 |
Adjust complete denture - maxillary |
15.00 |
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| 5411 |
Adjust complete denture - mandibular |
15.00 |
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| 5421 |
Adjust partial denture - maxillary |
15.00 |
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| 5422 |
Adjust partial denture - mandibular |
15.00 |
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*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. |
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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.
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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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