Pinellas County Public Schools
  Overview
  Schedule of Benefits
  Certificate of Coverage

  AVF Q & A

  Search for Providers
  MyCompBenefits
  Contact Information

 

 



Advantage AVF-1 Schedule of Benefits

Prosthetics (Dentures) Schedule

Limitations and Exclusions

ADA
CODE
Procedure Member
Pays
  REMOVABLE PARTIAL AND COMPLETE DENTURES  
  (Limit replacement to every 5 years)  
 
D5110 COMPLETE DENTURE-UPPER $498
D5120 COMPLETE DENTURE-LOWER $498
D5130 IMMEDIATE DENTURE-UPPER $543
D5140 IMMEDIATE DENTURE-LOWER $543
D5211 UPPER PARTIAL-RESIN BASE with CONVENTIONAL CLASPS - RESTS &TEETH $420
D5212 LOWER PARTIAL-RESIN BASE with CONVENTIONAL CLASPS - RESTS &TEETH $488
D5213 UPPER PARTIAL-CAST METAL RESIN BASE with CONVENTIONAL CLASPS $550
D5214 LOWER PARTIAL-CAST METAL RESIN BASE with CONVENTIONAL CLASPS $550
D5410 ADJUST COMPLETE DENTURE-UPPER $27
D5411 ADJUST COMPLETE DENTURE-LOWER $27
D5421 ADJUST PARTIAL DENTURE-UPPER $27
D5422 ADJUST PARTIAL DENTURE-LOWER $27
 
  PROSTHETIC REPAIRS  
 
D5510 REPAIR BROKEN COMPLETE DENTURE BASE $55
D5520 REPLACE MISSING/BROKEN TOOTH - COMPLETE DENTURE-EA TOOTH $46
D5610 REPAIR RESIN DENTURE BASE $59
D5620 REPAIR CAST FRAMEWORK $64
D5630 REPAIR OR REPLACE BROKEN CLASP $77
D5640 REPLACE BROKEN TEETH-PER TOOTH $50
D5650 ADDITIONAL TOOTH TO EXISTING PARTIAL DENTURE $68
D5660 ADD CLASP TO EXISTING PARTIAL DENTURE $82
D5710 REBASE COMPLETE UPPER DENTURE $202
D5711 REBASE COMPLETE LOWER DENTURE $193
D5720 REBASE UPPER PARTIAL DENTURE $191
D5721 REBASE LOWER PARTIAL DENTURE $191
D5730 RELINE COMPLETE UPPER DENTURE - CHAIRSIDE $114
D5731 RELINE COMPLETE LOWER DENTURE - CHAIRSIDE $114
D5740 RELINE UPPER PARTIAL DENTURE - CHAIRSIDE $105
D5741 RELINE LOWER PARTIAL DENTURE - CHAIRSIDE $105
D5750 RELINE COMPLETE UPPER DENTURE (LAB) $152
D5751 RELINE COMPLETE LOWER DENTURE (LAB) $152
D5760 RELINE UPPER PARTIAL DENTURE (LAB) $150
D5761 RELINE LOWER PARTIAL DENTURE (LAB) $150
D5850 TISSUE CONDITIONING, MAXILLARY $48
D5851 TISSUE CONDITIONING, MANDIBULAR $48

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%.

 



Return to Pinellas County Public Schools Home


 

 

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