Advantage AVF-1 Schedule of Benefits

Crowns and Bridges 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
		CROWNS
		(Limited to 1 crown per tooth every 5 years)
D2710		CROWN-RESIN (INDIRECT)		$162
D2720		CROWN-RESIN WITH HIGH NOBLE METAL		$400
D2721		CROWN-RESIN WITH PREDOM BASE METAL		$375
D2722		CROWN-RESIN WITH NOBLE METAL		$383
D2740		CROWN-PORCELAIN/CERAMIC SUBSTRATE		$411
D2750		CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL		$405
D2751		CROWN-PORCELAIN FUSED TO PREDOM BASE METAL		$377
D2752		CROWN-PORCELAIN FUSED TO NOBLE METAL		$386
D2790		CROWN-FULL CAST HIGH NOBLE METAL		$391
D2791		CROWN-FULL CAST PREDOM BASE METAL		$370
D2792		CROWN-FULL CAST NOBLE METAL		$377
		FIXED BRIDGES
		(Limit replacement to every 5 years)
D6210		PONTIC-CAST HIGH NOBLE METAL		$378
D6211		PONTIC-CAST PREDOM BASE METAL		$354
D6212		PONTIC-CAST NOBLE METAL		$369
D6240		PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL		$373
D6241		PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL		$345
D6242		PONTIC-PORCELAIN FUSED TO NOBLE METAL		$364
D6250		PONTIC-RESIN WITH HIGH NOBLE METAL		$369
D6251		PONTIC-RESIN WITH PREDOM BASE METAL		$340
D6252		PONTIC-RESIN WITH NOBLE METAL		$351
D6600		BRIDGE RETAINER-INLAY, PORCELAIN, 2 SURFACES		$312
D6601		BRIDGE RETAINER-INLAY, PORCELAIN, 3+ SURFACES		$327
D6602		BRIDGE RETAINER-INLAY, CAST HIGH NOBLE METAL, 2 SURFACES		$333
D6603		BRIDGE RETAINER-INLAY, CAST HIGH NOBLE METAL, 3+ SURFACES		$366
D6604		BRIDGE RETAINER-INLAY, CAST PREDOM BASE METAL, 2 SURF		$326
D6605		BRIDGE RETAINER-INLAY, CAST PREDOM BASE METAL, 3+ SURF		$346
D6606		BRIDGE RETAINER-INLAY, CAST NOBLE METAL, 2 SURFACES		$321
D6607		BRIDGE RETAINER- INLAY, CAST NOBLE METAL, 3+ SURFACES		$321
D6608		BRIDGE RETAINER-ONLAY, PORCELAIN, 2 SURFACES		$321
D6609		BRIDGE RETAINER-ONLAY, PORCELAIN, 3+ SURFACES		$353
D6610		BRIDGE RETAINER-ONLAY, CAST HIGH NOBLE METAL, 2 SURF.		$359
D6611		BRIDGE RETAINER-ONLAY, CAST HIGH NOBLE METAL, 3+ SURF		$393
D6612		BRIDGE RETAINER-ONLAY, CAST PREDOM BASE METAL, 2 SURF		$357
D6613		BRIDGE RETAINER-ONLAY, CAST PREDOM BASE METAL, 3+ SURF		$373
D6614		BRIDGE RETAINER-ONLAY, CAST NOBLE METAL, 2 SURFACES		$350
D6615		BRIDGE RETAINER-ONLAY, CAST NOBLE METAL, 3+ SURFACE		$363
D6720		CROWN-RESIN WITH HIGH NOBLE METAL		$416
D6721		CROWN-RESIN WITH PREDOM BASE META		$395
D6722		CROWN-RESIN WITH NOBLE METAL BOND		$402
D6740		BRIDGE RETAINER-CROWN, PORCELAIN		$438
D6750		CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL		$426
D6751		CROWN-PORCELAIN FUSED TO PREDOM BASE METAL		$398
D6752		CROWN-PORCELAIN FUSED TO NOBLE METAL		$407
D6780		CROWN-3/4 CAST HIGH NOBLE METAL		$402
D6790		CROWN-FULL CAST HIGH NOBLE METAL		$411
D6791		CROWN-FULL CAST PREDOM BASE METAL		$390
D6792		CROWN-FULL CAST NOBLE METAL		$404
D6930		RECEMENT BRIDGE		$50
D6970		CAST POST AND CORE IN ADDITION TO BRIDGE		$138
D6972		PREFABRICATED POST AND CORE IN ADDITION TO BRIDGE		$112
D6973		CORE BUILD-UP FOR BRIDGE, INCLUDING PINS		$91

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%.