Prestige 15 Schedule - Radiograph Services



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Prestige 15 Schedule¹

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SERVICES

RADIOGRAPHS

ADA Code	Procedure	Member Pays
0210	Intraoral � complete series	No Charge

0220	Intraoral � periapical � first film	No Charge

0230	Intraoral � periapical � each additional film	No Charge

0270	Bitewings � single film	No Charge

0272	Bitewings � two films	No Charge

0274	Bitewings � four films	No Charge

0330	Panoramic	No Charge

*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.

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.

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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