Loading...
HomeMy WebLinkAboutparagon2Group Dental Contract Addendum El® SHENANDOAH LIFE INSURANCE COMPANY Paragon COM 1000 Dental Plan and Shenandoah Ltfe Insurance Company Group Dental Insurance Policy Paragon Benefits and Shenandoah Life Insurance Company have partnered to offer a combination of Paragon's fee -for -service COM 1000 beneflt plan and Shenandoah Life's group Wellness Plan dental insurance policy to provide you with a comprehensive dental program. The Paragon COM 1000 Plan is a comprehensive fee -for -service benefit plan that is sponsored by a large network of dental providers throughout the State of Florida (network access). The Paragon COM 1000 Plan ensures that the provider does not charge a plan member any additional amount for preventive services for which benefits are payable under the Shenandoah Life dental insurance policy. The COM 1000 Dental Plan also provides a comprehensive fee -for -service benefit plan that covers additional preventive, basic, major, and orthodontic services with no waiting periods. The COM 1000 Plan fee schedule offers guaranteed co - payments on over 300 ADA Codes Ihat the provider cannot upgrade compared to an average of 140 ADA Codes fisted on typical capitated plans ensuring that the provider does not overcharge the patient. The patient co -payments for basic and major services represent significant savings. Orthodontia and Specialty services are also covered. (See the Schedule of Benefits for specific plan benefits). The combination of the COM 1000 Plan and the Wellness Plan provides your employees and their families with comprehensive dental care. The rates are guaranteed for one (1) year from the effective date of January 1, 2005. All administrative, reporting and account service functions are included. Status Paragon Administrative/Network Shenandoah Wellness Plan Total Monthly Premium Employee Family $7.48 $12.02 $4.70 $18.50 $12.18 $30.52 1 Int. Members of the COM 1000 dental plan are eligible to receive benefits immediately upon the effective date of coverage with: No waking periods ▪ No claim forma io submit by members The member co -payments listed are guaranteed to be up to a 75% discount and are offered by a participating Paragon provider. The member receives, ' Most diagnostic 8 preventive care at no charge • Cosmetic & orthodontia treatment Ths COM 1000 Dental Plan provider reimbursement Is underwritten by Shenandoah Life Insurance Company's Wellness pion. Members can choose a participating Paragon provider at www. Paraaonde nta l . com Member Services Deperlment 877-760•2247 The patient/member Is ultimately responsible for verificatlons to the accuracy and appropriateness of ell fees applicable to any Paragon dental benefit provided by a Paragon network provider. Paragon urges all of its members to verify el fees for proposed treatment via the "Schedule of Benicia" and/or with Paragon Member Services Department prior to treatment. The following member co•payments apply when a participating General Dentist performs services. Participating Specialists available at fees discounted off their usual and customary charges. DESCRIPTION APPOINTMENTS 0120 Periodic oral evaluation 0140 Limited oral evaluation - problem fowled 0160 Comprehensive oral evaluation • new or established patient 0160 Detailed and extensive oral evaluation - problem focused 0170 Re-evaluation • limited, problem focused 0180 Comprehensive periodontal evaluation - new or established patient 9110 Palliative (emergency) treatment of dental pain 9310 ConauNation (diagnostic service provided by dentist other than practitioner providing treatment) 9430 Office visit for observation lOSHA 9440 Office visit • after regularly scheduled hours 9490 Broken appointment fee JIADIOGRAPNYIDIAGNOSTIC DENTISTRY `0210 X•Ray • Intraoral • complete series (including bkewinge) OMB CO -PAY No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge 55.00 25.00 No Charge 2 COM 1000 Dental Plan COGS PE8cRJPT101( 0230 X-Ray • intraoral • periapical each additional film 0240 X-Ray • Intraoral - occlusal film 0250 X-Ray • extreoral • first film 0280 X•Ray • extraoral • each additional film 0270 X•Ray • bitewing • single film 0272 X•Ray • bitewing - two films '0274 X-Ray • bkawing - four films '0277 Vertical bitewings • 7 to 8 films 'Not to be taken if 0274 was done within prior six months. Copies of x-rays can be obtained for $2.00 per periapical film opt a maximum of $30.00. Panoramic x•ray can be obtained fora $16.00 fee. 0290 Post -ant or let skul and facial film 0310 Slalography 0320 TMJ, including injection 0321 Other TMJ Nms 0322 Tomographlc survey 0330 Panoramic fim (not to replace FMX) 0340 Cephalometric fllm, ma -orthodontic 0350 Orallfaclal Images (Inductee intro & extreorel) 0415 Bacteriologic studies 0425 Caries ausceptibiky tests 0480 Pulp vitality tests 0470 Diagnostic casts PREVENTIVE DENTISTRY 1110 Routine prophylaxis -adult (once every 6 months) 1110 Additional routine prophylaxis - adult 1120 Routine prophylaxis - children under the age of 18 (once every 6 months) 1120 Addltlonel routine prophylaxis -children under the age of 16) 1201 Topical application of fluoride (including prophylaxis) children under the age of 18 1203 Topical application of fluoride (excluding prophylaxis) children under the age of 18 1204 Topical application of fluoride (excluding prophylaxis) adult 1208 Topical application of fluoride (including prophylaxis) adult t 310 Nutritional counseling for control of dental disease 1320 Tobacco counseling for the control & prevention of oral disease 1330 Oral hygiene instructions 1351 Application of sealant per tooth • ohkdren under the age of 18 1510 Space maintainer • fixed - unilateral - children under the age of 18 1515 Space maintainer • fixed - bilateral - chldren under the age of 16 1520 Space maintainer - removable - unilateral chldren under the age of 18 1525 Space maintainer - removable - bilateral chldren under the age of 18 1660 Recementatlon of apace maintainer 8210 Removable appliance therapy MEAIt3ER GO•PAY No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge 150.00 180.00 250.00 150.00 160.00 No Charge 75.00 20.00 No Charge No Charge No Charge No Charge No Charge 60.00 No Charge 38.00 No Charge No Charge 5.00 5.00 No Charge No Charge No Charge 15.00 88.00 86.00 95.00 95.00 10.00 103.00 Int. 0220 X-Ray - intraoral • periapical first film No Charge 8220 Fixed appliance therapy 103.00 CODE DESCRIPTION RESTORATIVE DENTISTRY 2140 Amalgam • 1 surface, primary or permanent 2150 Amalgam • 2 surfaces, primary or permanent 2160 Amalgam • 3 surfaces, primary or permanent 2161 Amalgam -4 surfaces, primary or permanent 2330 Resin -based composite -1 surface, anterior 2331 Rash -based composite • 2 surfaces, anterior 2332 Resin•based composite • 3 surfaces, anterior 2335 Resin•based composite • or involving incise angle (anterior) 2390 Resin•based composite crown, anterior 2391 Resin -based composite • 1 surface, posterior 2392 Resin -based composite - 2 surfaces, posterior 2393 Resin -based composite • 3 surfaces, posterior 2394 Resin -based composite • 4 or more surfaces, posterior 2410 Gold fait • 1 surface 2420 Gold foil • 2 surfaces 2430 Gold foil • 3 surfaces 2510 Inlay • metallic • 1 surface 2620 Inlay • metallic • 2 surfaces 2530 Inlay • metallic • 3 ar more surfaces 2542 Onlay • metallic -2 surfaces 2543 Onlay • metallic -3 surfaces 2644 Onlay • metallic • 4 ar more surfaces 2610 Inlay• porcelain/ceramic-1 surface 2620 Inlay • porcelain/ceramic - 2 surfaces 2830 Inlay • porcelain/ceramic • 3 ar more aurtacea 2642 Onlay - porcelain/ceramic • 2 surfaces 2643 Onlay • porcelain/ceramic - 3 surfaces 2644 Onlay - porcelain/ceramic -4 or more surfaces 2650 Inlay - resln•based composite • 1 surface 2651 Inlay - resin•based composite • 2 surfaces 2852 Inlay - reein•based composite -3 ar more surfaces 2662 Onlay • resin -based composite - 2 surfaces 2883 Onlay • resin -bated composite • 3 surfaces 2864 Onlay • resin -based composite • 4 or more surfaces 2710 Crown • resin (Indirect) 2720 Crown - resin with high noble metal 2721 Crown • resin with predominantly base metal 2722 Crown • resin with noble metal 2740 Crown • porcelalnlceramfc substrate 2750 Crown • porcelain fused to high noble metal 2751 Crown • porcelain fused to predominantly base metal 2752 Crown • porcelain fused to noble metal 2780 Crown -3/4 cast high noble metal 2781 Crown - 314 cast predominarty base metal 2782 Crown - 3/4 cast noble metal 2783 Crown -314 porcelain/ceramic 2790 Crown • ful cast high noble metal 2791 Crown • full cast predominantly base metal 2792 Crown • full cast noble metal 2799 Pmvisional crown 2910 Recemenl inlay 2920 Recemerrt crown 2930 Prefabricated stainless steel crown • primary tooth 2931 Prefabricated stainless steel crown • permanent tooth 2932 Prefabricated resin crown 2933 Prefabricated stainless steel crown with resin window 2940 Sedative filling 2950 Care buildup, Including any pine 2951 Pin retention - per lath. In addition to restoration 2952 Cast post and core In addition to crown 2953 Each additional cast post • same tooth 2954 Prefabricated post and core in addition to crown No Charge Na Charge Na Charge Na Charge No Charge No Charge No Charge IIEMBEE MBE C.Q111 DESCRIPTION CO•PAY 2961 Labial veneer (resin laminate) • laboratory 2962 Labial veneer (porcelain laminate) • laboratory 2970 Temporary crown (fractured tooth) 2980 Crown repair When crown and/ar bridgework exceeds six (6) consecutive units, an additional charge of $30.00 per unit applies. ENDODONTIC SERVIC§§ 75,00 75,00 30.00 40.00 55.00 75.00 65.00 90.00 120.00 235.00 235.00 235.00 285.00 285.00 285.00 275.00 275.00 275.00 300.00 300.00 300.00 200.00 200.00 200.00 235.00 235.00 235.00 195.00 270.00 270.00 270.00 365.00 355.00 285.00 345.00 355.00 285.00 pERIODOMTIC SERVICE$ 345.00 350,00 355.00 285.00 346.00 125.00 No Charge No Charge 60.00 80,00 70.00 130.00 No Charge 90.00 15.00 105.00 95.00 90.00 3 3110 Pulp cap - direct (excluding final restoration) 3120 Pulp cap • Indirect (excluding final restoration) 3220 Therapeutic pulpotomy (excluding final restoration) 3221 Pulpai debridement, primary and permanent teeth 3230 Pulpal therapy (resorb filing)-anteror, primary 3240 Pulpal therapy (resorbabls filing) - posterior, primary 3310 Endodontic therapy • anterior (excluding final restoration) 3320 Endodontic therapy • bicuspid (excluding final restoration) 3330 Endodontic therapy • molar (excluding final restoration) 3331 Treatment of root canal obstruction; non-aurglcal access 3332 Incomplete endodontic therapy, Inoperable or fractured tooth 3333 Internal root repair of perforation defeats 3346 Retreatment of previous root canal therapy • anterior 3347 Retreatment of previous root canal therapy - bicuspid 3348 Retreatment of previous root canal therapy - molar 3351 Apexlficatlonlrecalcifcation - Initial visit 3352 Apexificatlodrecatclfcatlon • Interim medication replacement 3353 Apexillcatiordrecalciflcatbn • final visit 3410 Aplcoectomylperiradlcvler surgery • anterior 3421 Aplcaedomylperlradicular surgery • bicuspid (first root) 3426 Aplcoedomylperlradicular surgery • molar (first root) 3426 Aplcoedomy/perlradicular surgery • each additional root 3430 Retrograde filing • per root 3450 Root amputation • per mot 3470 Intentional relmplantetlon (Including splinting) 3910 Surgical procedure for Isolation of tooth with rubber dam 3920 Hemisectlon (including root removal) 3950 Canal preparation and fitting of preformed dowel or Poe 4210 Ginglvectomylgirrglvaplasty • 4 or more contiguous teeth per quad 4211 Gingivectomylgingivaplaaty - 1 to 3 teeth, per quad 4220 Gingival curettage per quadrant (excluding root planing) 4240 Gingival flap procedure, including mot planing • 4ormore 4241 Gingival flap procedure, Including root planing • Ito 3 teeth, per quad 4245 Apicaly postponed flap 4249 Clinical crown lengthening • hard tissue 4260 Osseous surgery (including flap entry and closure) 4 or more contiguous teeth par quad 4261 Osseous surgery (Including flap entry and closure) 1 to 3 teeth per quadrant 4263 Bone replacement graft - first site In quadrant 4264 Sons replacement graft - each additional sae In CO -PAY 350.00 485.00 75.00 95.00 No Charge Na Charge 85.00 65.00 60.00 65,00 125.00 215.00 305.00 65.00 65.00 66.00 145.00 250.00 385.00 90.00 90.00 90.00 176.00 175.00 175.00 100.00 35.00 85.00 176.00 95,00 80.00 75.00 135.00 60.00 40.00 160.00 160.00 160.00 135.00 395.00 236.00 225.00 Int. 2955 Past removal (not in conjunction with endodontic therapy) 2957 Each additional prefabricated post • same tooth 2960 Labial veneer (resin laminate) • chalrelde QQQk pESCRIPTIOP 4287 Guided tissue regeneration • nonresorbable barrier, per site 4270 Pedi le soft tissue graft procedure 4271 Free soft lime graft procedure (including donor site surgery) 4273 Subeptthetlel connective tissue graft procedures 4274 Distal or proximal wedge procedure 4341 Periodontal scaling and root planing -4 or more contiguous teeth per quadrant 4342 Periodontal scaling and root planing • 110 3 teeth, per quadrant 4365 Full mouth debrklement to enable comprehensive evaluation and diagnosis 4381 Localized delivery of chemotherapeutic agents via a controlled release vehicle Into diseased crevicuiar tissue, per tooth 4910 Periodontal maintenance 4920 Unscheduled dressing change (by someone other than the treating dental office) pROSTH0D0NTICS•REMOVABLE 5110 Complete denture • maxilary 5120 Complete denture • mandibular 5130 Immediate denture - maxillary (including two relines) 5140 Immediate denture - mandibular (including two relines) 5211 Maxilary partial denture • min base (including clasps) 5212 Mandibular partial denture - resin base (including clasps) 5213 Partial denture • maxilary cast metal • acrylic 5214 Partial denture - mandibular cast metal - acrylic 5281 Removable unilateral partial denture - one piece cast metal 6410 Adjustment • complete denture - maxilary 5411 Adjustment - complete denture • mandibular 5421 Adjustment - partial denture - maxilary 5422 Adjustment - partial denture - mandibular (All denture adjustment charges are for dentures which were not fabricated In the present office; all denture adjustments for new dentures or dentures made within Iwelve (12) months are at No Charge) 5610 Repair broken complete denture base 5520 Replace broken tooth • complete derdure (each tooth) 5610 Repair denture resin base 5620 Repak cast framework 5630 Repel( or replace broken clasp 5640 Repair broken teeth • per tooth 5650 Add tooth to existing partial denture 5680 Add clasp to existing partial denture 5710 Rebase complete maxillary denture 5711 Rabies complete mandibular denture 5720 Rebase maxilary partial denture 5721 Rebase mandibular partial denture 5730 Reline complete maxillary denture (chairalde) 6731 Reline complete mandibular denture (chairelde) 5740 Reline partial maxilary denture (chetreide) 6741 Reline partial mandibular denture (chairakle) 5750 Reline complete maxilary denture (laboratory) 5751 Reline complete mandibular denture (laboratory) 5760 Reline partial maxilary denture (laboratory) 5761 Reline partial mandibular denture (laboratory) 6810 Interim complete denture • maxillary 6811 Interim complete denture • mandibular 5820 Interim partial denture - maxillary 5821 Interim partial denture • mandibular 5850 Tissue condlianing • maxillary 5851 Tissue conditioning • mandibular 5862 Precision attachment 5899 Denture cleaning PROSTHODONTICB • FIXPD 20.00 quadrant 30.00 4286 Guided tissue regeneration • resorbabie barrier, 75.00 per site MEMBER CO -PAY 201 OISCRIPTIO ( 335.00 8241 Pontic • porcelain fused to predominantly base metal 226.00 6242 Pontic • porcelain fused to noble metal 226.00 6245 Pantie - porcelain/ceramic 280.00 6250 Pontic • resin with high noble metal 100.00 8251 Pantie • resin with predominantly base metal 6252 Poetic - resin with noble metal 60.00 6545 Retainer • cast metal for resin bonded fixed prosthesis 35.00 8648 Retainer - porcelain/ceramic for resin bonded fixed prosthesis 60.00 6720 Crown - resin whh high noble metal 6721 Crown - resin with predominantly base metal 80.00 6722 Crown - resin whh noble metal 45.00 6740 Crown - porcelain/ceramic 6750 Crown - porcelain fused to high noble metal 20.00 6751 Crown - porcelain fused to predominardly base metal 8752 Crown • porcelain fused to noble metal 6780 Crown - 314 cast high noble metal 6781 Crown • 314 cast predominantly base metal 320.00 8782 Crown - 314 cast noble metal 320.00 8783 Crown • 314 porcelain/ceramic 320.00 8790 Crown • ful cast high noble metal 320.00 6791 Crown - ful cast predominantly base metal 290.00 6792 Crown • ful cast noble metal 290.00 8930 Reoement fixed partial denture 360.00 6940 Stress breaker 360.00 6950 Precision attachment 6970 Cast poet and core In addition to fixed partial 330.00 denture retainer 15.00 6971 Cast post as part of a fixed partial denture retainer 15.00 6972 Prefabricated poet and care in addition to fixed partial 15.00 denture retainer 15.00 8973 Core build up for retainer, Including pins 6975 Coping • metal 8976 Each additional cast poet - same tooth 8977 Each additional prefabricated post - same tooth 50.00 60.00 ORAL 1109ERY 50.00 50.00 50.00 50.00 50.00 50.00 105.00 105,00 105.00 105.00 60.00 80.00 60.00 60.00 105.00 105.00 105.00 105.00 166.00 165.00 125.00 125.00 25.00 25.00 150.00 No Charge 7111 Coronet remnants • deciduous tooth 7140 Extraction of erupted tooth or exposed root 7210 Surgical removal of erupted tooth 7220 Removal of impacted tooth • soft tissue 7230 Removal of impacted tooth - partially bony 7240 Removal of impacted tooth • completely bony 7241 Removal of impacted tooth • completely bony, with unusual surgical complications 7250 Surgical removal of residual tooth roots 7280 Oroarrtral fistula closers 7270 Tooth reknplantation 7280 Surgical access of an unerupted tooth 7281 Surgical exposure of impacted or unerupted tooth to aid eruption 7285 Biopsy of oral tissue • hard (bone, tooth) 7286 Biopsy of oral tissue - soft (al others) 7310 Alveolopiasty with extractions • per quadrant 7320 Alveolopleety without extractions - per quadrant 7460 Removal of odontogenic cyst or tumor up to 1.25 cm 7451 Removal of odontogenic cyst or tumor greater than 1.25 cm 7510 Incision and drainage of abscess - intraoral soft tissue 7080 Frenulectomy • separate procedure 7970 Excision of hyperplastkc tissue - per arch 175.00 295.00 MEMBER co -PA( 280.00 340.00 365.00 350.00 350,00 350.00 180.00 376.00 385.00 385.00 365.00 385.00 355.00 285.00 345.00 355,00 285.00 345.00 345.00 356.00 285.00 345.00 No Charge 125.00 126.00 125.00 105.00 30.00 25.00 95.00 75.00 75.00 45.00 No Charge 80.00 45.00 85.00 125.00 125.00 60.00 140.00 No Charge No Charge No Charge 95.00 75.00 65.00 86.00 No Charge No Charge No Charge No Charge 140.00 MISCELLANEOUS SERVICES 4 9215 Local anesthesia No Ctge 6210 Portb • cast high node metal 6211 Pontio • cast predominantly base metal 6212 Ponilc • caal noble metal 6240 Poniic - porcelain fused to high noble metal 350.00 280.00 340.00 350.00 MEM 2.421 DESCRIPTN)N CO•PAY 9241 Intravenous sedatbNanalgesla • first 30 minutes 9242 Intravenous conscious sedatbnlenelgesia - each additional 15 minutes 9830 Oral irrigation/other drugs/medicament 9910 Application of desenskizing medicament 9940 Occlusal guard 9950 Occlusal natives • mounted case 9951 Occlusal adjustment • limited 9952 Occlusal adjustment - complete 9972 Cosmetic bleaching • per arch 9972 Cosmetic bleaching - both arches (Exduding blotching material for home use) 115.00 80,00 15.00 per quadrant 20.00 155.00 75.00 40.00 120.00 150.00 275.00 Emergency treatment is available for palliative treatment for the abatement of pain up to $100.00 per occurrence outside the service area (Florida). ORTHODONTIA 8680 Pre•arthodontic treatment visit 8999 Orthodortictreatment plan& records 8020 Lfmhed orthodontic treatment of the transitional dentition (up to 24 months) 8030 Limited orthodontic treatment of the adolescent dentition (up to 24 months) 8040 Limited orthodontic treatment of the adult dentition (up 10 24 months) 8070 Comprehensive orthodontic treatment of the transitional &maim (ful treatment case up to 24 months - including fixed/removable appliances) 8080 Comprehensive orthodontic treatment of the adolescent dentition (full treatment case up to 24 months - including fixed/removable appliances) 8090 comprehensive orthodontic treatment of the adult dentition (full treatment case up to 24 months Including fixed/removable appliances) 8880 Orthodontic retention (removal of appliances, construction and placement of retainer(s) (Includes fee for fired/removable retainers and monthly vlaks) Orthodontic treatment is prorated over 24 months and Is only payable under a current status. Prior wrkten authorization is necessary for a referral to an orthodontist designated by Paragon. 40.00 250.00 1,300.00 1,300.00 1,350,00 1,850.00 1,700.00 2,300.00 300.00 9220 General anesthesia • }iret 30 minutes 9221 General anesthesia - each additional 15 minutes 9230 Analgesia nitrous oxide 1. 2. 3. 4. 5. 8. 7, 6. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. PARAGON SPECIALTY SERVICE$ 1. This member Schedule of Benefits applies when listed dental services are performed by a participating general dentist, unless otherwise authorized by Paragon Benefits. 2, Procedures not listed on the Schedule of Benefits that are performed by a participating general dentist wit be charged at the participating general dentist's usual and customary fee less 25%. 3. The participating general dentist you select may not perform all procedures listed. The co -payments sheen apply to participating general dentists who do perform these services. Therefore, you are encouraged to secure availability of the scheduled services with your participating general dentist. 4. Should the services of a epeciel et (Oral Surgeon, Endadonfist, Orthodontist, Periodontist, Prosthodontlst or Pedodontist) be necessary, you may receive this care in ether of two ways: (1) You may go directly to a participating specialist with no referral and receive a 25% reduction Otto provider's usual and customary fee; or (2) You may request apecidly ser ene to be provided at the listed co -payments on your benefits schedule by obtaining prior written authorization from Paragon, Should Paragon, under its sole discretion, elect to provide the desired benefit, a specific referral wil be made to a designated ep5da11at. g)ICLUSIONSILIMITATIONS 115.00 60.00 20.00 per 1!2 hour Any oral evaluation is limited to ono (1) time in any six (6) consecutive month period at no charge. All subsequent oral evaluations wll be at a 25% discount off the doctor'a usual end customary fee without a frequency limitation. Skewing *rays (2-4 films) are Imted to one set In any twelve (12) consecutive month period. The denlel prophylaxis or periodontal maintenance procedure is limited to one In any six (6) consecutive month period, Any additional procedures wit Maw 1110 and 4910 member co -payments as listed in the schedule of benefits. Fluoride treatment Is limited to one (1) In any twelve (12) consecutive month period for chidren under the age of 16. Sealants are limited to one (1) time per tooth in any three (3) consecutive year period. This Is only allowed for unrestored permanent meter teeth for chldren under the we of 16. Space maintainers and al adjustments are IlmNed to children under the age of 18, Harmful habit appliances are limited to one (1) time per person under the age of 16. Services performed by a dentist or dental specialist, not contracted with Paragon without prior approval. Any dental services or appliances which are determined to be not reasonable and/or necessary for maintaining or improving the member's dental health, or experimental in nature, as determined by the participating Paragon dentist. Orthographic surgery or prooeduree and epplhanes, for the treatment of myofurrdlonal, myoskeietal or temperomandibular joint disorders unless otherwise specified as an orthodontic benefit on the Schedule of Benefits. General anesthesia or IV sedation unless otherwise listed as a covered benefit on the Schedule of Benefits, Any Inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, prescriptions, or mediations. Treatment of malignancies, cysts, or neoplasms. Dental implants and related services. Dental procedures Intfated prior to the member's eligibility under this benefit plan or started after the members termination from the plan. Any dental procedure or treatment unable to be performed In the dental office due to the general health or physical limitations of the member Induding but not limited to physical or emend resistance, inability to visit the dental office, or allergy to commonly utilized local anesthetics. New dentures Include one (1) reline wkhln the ikat six (6) months. Replacement of crowns, taxed bridges or dentures is limited to ounce every five (5) yeare, When crown and/or bridgework exceed ebc (6) consecutive unite, there will be an additional charge of $30.00 per unN. Co -payments for endodortic procedures do not Include the cost of the final restoration. Any fixed, rsstoretfve or removable prosthetic service may require additional costs to patient as blow High noble metal (precious) up to $130.00 Noble metal (semi-precious) unto $110.00 Predominantly hese metal (non•precious) up to $55.00 Crown laboratory fees up to $125.03 Laboratory fees on dentures up to $200.00 Porcelain laboratory fees for 2610 - 2644, 2962, 2740 up 10 $50.00 Denture repair laboratory fees up to $40.00 Int.