 | 
| Dallas Independent School
District Dental Member | | | | | | | | | | | | | | | | | | | | |
Texas Dental Plan (TDP) Schedule1
| 1Select a service below | | | | SERVICES | | | | | | | | | | | | | | | | PROSTHODONTIC DENTISTRY (Dentures)* | | | | | | | ADA
Code | | Procedure | | Member
Pays |  | | D5110 | | Complete denture - maxillary* | | $414 + LAB | | | | D5120 | | Complete denture - mandibular* | | 414 + LAB | | | | D5211 | | Maxillary partial denture - resin base (including any conventional clasps, rests and teeth)* | | 403 + LAB | | | | D5212 | | Mandibular partial denture - resin base (including any conventional clasps, rests and teeth)* | | 403 + LAB | | | | D5213 | | Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)* | | 403 + LAB | | | | D5214 | | Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)* | | 403 + LAB | | | | | | Prosthetics (dentures) fees are our reduced fees for usual and customary services. Any prosthetic appliance that requires unusual services may be an additional charge. Discuss all fees with the general dentist prior to any treatment. | | | | *Lab fees are additional and are not subject to plan discounts | All of the listed charges are reduced fees for services performed by a participating general dentist. Fees are subject to change without notice.
Any procedure not listed is available on a fee for service basis at a 20% discount. Consult with your participating general dentist prior to beginning any treatment. | | | Specialist Services
Any treatment provided by a participating specialist, if available, in Endodontics (root canal), Pediatric Dentistry (children's dentistry), Prosthodontics (Dentures), Orthodontics (teeth straightening), Periodontics (gum disease treatment) or Oral Surgery, will be charged at a 20% reduction of participating specialist's fees for that particular case. Some specialists may require a consultation visit before treatment is initiated. Discuss each case with the specialist prior to beginning any treatment. | | | |
