| PROSTHODONTICS (FIXED) |
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ADA
Code |
|
Procedure |
|
Member
Pays |
 |
| 6210* |
|
Pontic - cast high noble metal |
|
280.00 |
 |
| 6211 |
|
Pontic - cast predominantly base metal |
|
280.00 |
|
| 6212* |
|
Pontic - cast noble metal |
|
280.00 |
|
| 6240* |
|
Pontic - porcelain fused to high noble
metal |
|
280.00 |
|
| 6241 |
|
Pontic - porcelain fused to
predominantly base metal |
|
280.00 |
|
| 6242* |
|
Pontic - porcelain fused to noble metal |
|
280.00 |
|
| 6750* |
|
Crown - porcelain fused to high noble
metal |
|
280.00 |
|
| 6751 |
|
Crown - porcelain fused to
predominantly base metal |
|
280.00 |
|
| 6752* |
|
Crown - porcelain fused to noble metal |
|
280.00 |
|
| 6790* |
|
Crown - full cast high noble metal |
|
280.00 |
|
| 6791 |
|
Crown - full cast predominantly base
metal |
|
280.00 |
|
| 6792* |
|
Crown - full cast noble metal |
|
280.00 |
|
| 6930 |
|
Recement fixed partial denture
(per unit) |
|
10.00 |
|
|
6792* |
|
Adjust partial denture - mandibular |
|
15.00 |
|
| 6930 |
|
Adjust partial denture - mandibular |
|
15.00 |
|
| |
*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. |
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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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