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Jackson Memorial Hospital
Dental Members |
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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 |
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| Services |
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| Prosthetic Services |
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| Procedure |
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Member
Pays |
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| 5110 |
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Complete upper denture (standard) |
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$230 |
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| 5120 |
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Complete lower denture (standard) |
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230 |
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| 5130 |
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Immediate upper denture (standard) |
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245 |
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| 5140 |
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Immediate lower denture (standard) |
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245 |
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| 5210 |
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Partial upper or lower - acrylic, w/o
clasps |
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120 |
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5211/
5212 |
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Partial upper or lower - acrylic, 2 clasps, rests |
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240 |
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5213/
5214 |
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Partial upper or lower - chrome cast, 2 clasps,
2 rests |
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275 |
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5730/
5731 |
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Reline or rebase complete upper or lower
denture
(office, 1 every 36 months) |
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25 |
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5740/
5741 |
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Reline or rebase partial upper or lower
denture
(office, 1 every 36 months) |
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25 |
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5750/
5751 |
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Reline or rebase complete upper or lower
denture
(laboratory, 1 every 36 months) |
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55 |
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5760/
5761 |
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Reline or rebase partial upper or lower
denture (laboratory, 1 every 36 months) |
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55 |
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| 5850 |
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Soft tissue conditioner |
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No Charge |
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5410/
5411 |
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Adjustments - partials upper or lower |
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limit 3, new or existing |
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No Charge |
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after 3, per adjustments |
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5 |
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5421/
5422 |
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Adjustments - partial upper or lower |
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limit 3, new or existing |
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No Charge |
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after 3, per adjustments |
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5 |
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| 5001 |
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Denture prophylaxis (1 every 6 months) |
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No Charge |
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| 5002 |
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Additional clasps (per clasp) |
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25 |
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| Note |
The co-payments listed are the maximum fees that will be charged by
the Participating General Dentist for the specified covered services.
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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.
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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.
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Specialist services are available only in
areas where American Dental plan has a Participating Specialist.
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