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OHS Standard 200 Plan Schedule of Benefits1

The co-payments listed are the maximum fees that will be charged by the Participating General Dentist for the specified covered services.

1Select a service below
Services
bulletAppointments
bulletDiagnostics
bulletX-Rays
bulletPreventive
bulletRestorative
bulletOral Surgery
bulletCrowns and Bridges
bulletEndodontics
bulletPeriodontics
bulletProsthetics
bulletOrthodontics
bulletLimitations and Exclusions

 

Crown & Bridge Services
 
Procedure

Member
Pays

2970 Temporary crown
(in conjunction with permanent crown)
No Charge
2932 Crown - resin (prefabricated) $25
2740 Crown - porcelain 210
2751 Crown - porcelain fused to base metal 210
2752 Crown - porcelain fused to noble metal 250
2791 Crown - full cast base metal 210
2792 Crown - full cast noble metal 250
2930 Crown - stainless steel (primary - child) 25
2954 Post (prefab) and core buildup
(in addition to crown)
70
6751 Bridge abutment - porcelain fused to base metal per unit) 210
6241 Bridge pontic -porcelain fused to base metal (per unit) 210
6752 Bridge abutment - porcelain fused to noble metal (per unit) 250
6242 Bridge pontic -porcelain fused to noble  metal (per unit) 250
2335 Bonding (tooth reconstruction including incisal edge)
(anteriors only)
60
6545 Bonding Maryland bridge pontic (per unit) 200
6546 Bonding Maryland bridge abutment
(per unit)
60
2910 Recement inlay (per unit) 10
2920 Recement crown (per unit) 10
6930 Recement bridge (per unit) 20


Note
Per unit, up to six (6) units. Seven (7) or more units, add an additional $40 per unit. Laboratory processed temporary splint, add an additional $25 per unit for seven (7) or more units.

The co-payments listed are the maximum fees that will be charged by the Participating General Dentist for the specified covered services.

Should you need a specialist (i.e., Endodontist, Orthodontist, Oral Surgeon, Periodontist, Prosthodontist, Pediatric Dentist), you may refer yourself to any Participating Specialist from our directory, Upon identifying yourself as an American Dental Plan member, you will receive a 25% reduction from usual and customary fees for services performed.

All procedures listed may not be performed by the Participating General Dentist. Therefore, you are encouraged to discuss availability of the scheduled services with your Participating General Dentist.

Specialist services are available only in areas where American Dental plan has a Participating Specialist.

 

 

Current Dental Terminology © 2004 American Dental Association. All rights reserved

 

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