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HomeMy WebLinkAboutExhibit7ra on. its Solutions, Inc dental Group Dental Contract Addendum ® SHENANDOAH LIr+ FIJI INSURANCE COMPANY Paragon COM 1000 Dental Plan and Shenandoah Life 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 benefit 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 that the provider cannot upgrade compared to an average of 140 ADA Codes listed 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 dale of coverage with: ' No wailing periods • No claim forms to 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 & preventive care al no charge ' Cosmetic & orthodontia treatment The COM 1000 Dental Plan provider reimbursement is underwritten by Shenandoah Life Insurance Company's Wellness plan. Members can choose a participating Paragon provider at www.paragondental.com Member Services Department 877-760.2247 The patient/member is ultimately responsible for verifications to the accuracy and appropriateness of all fees applicable to any Paragon denial benefit provided by a Paragon c work provider. Paragon urges all of its members to verify all fees for proposed treatment a Me 'Schedule of Benefits' 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. CODE DESCRIPTION APPOINTMENTS 0120 Periodic oral evaluation 0140 Limited oral evaluation - problem focused 0150 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 Consultation (diagnostic service provided by dentist other than practitioner providing treatment) 9430 Office visit for observation/OSHA 9440 Office visit - after regularly scheduled hours 9490 Broken appointment fee RADIOGRAPHY/DIAGNOSTIC DENTISTRY •0210 X-Kay - inlraoral - bilewings) 0220 X-Ray - inlraoral - periapical first trim MEMBER 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 No Charge 2 COM 1000 Dental Plan CODE DESCRIPTION 0230 X-Ray - inlraoral - periapical each additional film 0240 X-Ray - inlraoral - occlusal film 0250 X-Ray - exlraoral - first film 0260 X-Ray - exlraoral - each additional film 0270 X-Ray - bitewing - single film 0272 X-Ray - bitewing - Iwo films '0274 X-Ray - bitewing - four films '0277 Vertical bilewings - 7 to 8 films 'Not to be taken i(0274 was done within prior six months. Copies of x-rays can be obtained for $2.00 per periapical film up to a maximum of $30.00. Panoramic x-ray can be obtained for a $15.00 fee. 0290 Post -ant or tat skull and facial film 0310 Sialography 0320 TMJ, including injection 0321 Other TMJ films 0322 Tomographic survey 0330 Panoramic film (not to replace FMX) 0340 Cephalometric film, non -orthodontic 0350 Oral/facial images (includes infra 8 exlraoral) 0415 Bacterialogic studies 0425 Caries susceptibility tests 0460 Pulp vitality tests 0470 Diagnostic casts PREVENTIVE DENTISTRY 1110 Routine prophylaxis-adull (once every 6 months) 1110 Additional routine prophylaxis - adufl 1120 Routine prophylaxis - children under the age of 16 (once every 6 months) 1120 Additional routine prophylaxis - children under the age of 16) 1201 Topical application of fluoride (including prophylaxis) children under the age of 16 1203 Topical application of fluoride (excluding prophylaxis) children under the age of 16 1204 Topical application of fluoride (excluding prophylaxis) adult 1205 Topical application of fluoride (including prophylaxis) adult 1310 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 • children under the age of 16 1510 Space maintainer - fixed - unilateral - children under the age of 16 1515 Space maintainer - fixed - bilateral - children under the age of 16 1520 Space maintainer - removable - unilateral children under the age of 16 1525 Space maintainer - removable - bilateral children under the age of 16 1550 Re -cementation of space maintainer 8210 Removable appliance therapy 8220 Fixed appliance therapy MEMBER CO -PAY No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge 150.00 150.00 250.00 150.00 150.00 No Charge 75.00 20.00 No Charge No Charge No Charge No Charge No Charge 50.00 No Charge 35.00 No Charge No Charge 5.00 5.00 No Charge No Charge No Charge 15.00 85.00 85.00 95.00 95.00 10.00 103.00 loaoo Int. 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 Resin -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 foil -1 surface 2420 Gold foil - 2 surfaces 2130 Gold foil - 3 surfaces 2510 Inlay - metallic - 1 surface 2520 Inlay - metallic - 2 surfaces 2530 Inlay - metallic - 3 or more surfaces 2542 Onlay - metallic - 2 surfaces 2543 Onlay - metallic - 3 surfaces 2544 Onlay - metallic - 4 or more surfaces 2610 Inlay - porcelain/ceramic -1 surface 2620 Inlay - porcelainfceramic - 2 surfaces 2630 inlay - porcelainlceramic - 3 or more surfaces 2642 Onlay - porcelain/ceramic - 2 surfaces 2643 Onlay - porcelain/ceramic - 3 surfaces 2644 Onlay • porcelain/ceramic - 4 or more surfaces 2650 Inlay - resin -based composite -1 surface 2651 Inlay - resin -based composite - 2 surfaces 2652 Inlay - resin -based composite - 3 or more surfaces 2662 Onlay - resin -based composite - 2 surfaces 2663 Onlay • resin -based composite - 3 surfaces 2664 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 - porcelain/ceramic 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 - 3/4 cast predominantly base metal 2782 Crown - 3/4 cast noble metal 2783 Crown - 3/4 porcelain/ceramic 2790 Crown - full cast high noble metal 2791 Crown - full cast predominantly base metal 2792 Crown - full cast noble metal 2799 Provisional crown 2910 Recement inlay 2920 Recement crown 2930 Prefabricated stainless steel crown - primary tooth 2931 Prefabricated stainless steel aown - permanent tooth 2932 Prefabricated resin crown 2933 Prefabricated stainless steel Gown with resin window 2940 Sedative filling 2950 Core buildup, including any pins 2951 Pin retention - per tooth, 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 2955 Post removal (not in conjunction with endodontc therapy) 2957 Each additional prefabricated post - same tooth 2960 Labial veneer (resin laminate) - chairside MEMBER CO -PAY No Charge No Charge No Charge No Charge No Charge No Charge No Charge 75.00 75.00 30.00 40.00 55.00 75.00 65.00 90.00 120.00 235.00 235.00 235.00 285.00 285.00 285.00 275.00 275.00 275.00 300.00 300.00 300.00 200.00 200.00 200.00 235.00 235.00 235.00 195.00 270.00 270.00 270.00 365.00 355.00 285.00 345.00 355.00 285.00 345.00 350.00 355.00 285.00 345.00 125.00 No Charge No Charge 60.00 60.00 70.00 130.00 No Charge 90.00 15.00 105.00 95.00 90.00 20.00 30.00 75.00 MEMBER CODE DESCRIPTION CO -PAY 2961 Labial veneer (resin laminate) - laboratory 350.00 2962 Labial veneer (porcelain laminate) - laboratory 485.00 2970 Temporary crown (fractured tooth) 75.00 2960 Crown repair 95.00 When crown and/or bridgework exceeds six (6) consecutive units, an additional charge of $30.00 per unit applies. END0D0NTIC SERVICES 3110 Pulp cap - direct (excluding final restoration) 3120 Pulp cap - indirect (exduding final restoration) 3220 Therapeutic pulpolomy (excluding final resloralion) 3221 Pulpal debridemenl, primary and permanent teeth 3230 Pulpal therapy (resorb filling) - anterior, primary 3240 Pulpal therapy (resorbable filling) - 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 -surgical access 3332 Incomplete endodontc therapy; inoperable or fractured tooth 3333 Internal root repair of perforation defects 3346 Relrealment of previous root canal therapy - anterior 3347 Retreatmenl of previous root canal therapy - bicuspid 3348 Relrealment of previous root canal therapy - molar 3351 Apexificalion/recalcificalion - initial visit 3352 Apexificalion/recalcificalion - interim medication replacement 3353 Apexificalion/recalcificalion - final visit 3410 Apicoeclomy/periradicular surgery - anterior 3421 Apcoeclomy/periradicular surgery - bicuspid (first root) 3425 Apicoectomy/periradicular surgery - molar (first root) 3426 Apicoedomy/periradicular surgery - each additional root 3430 Retrograde filling - per root 3450 Root amputation - per root 3470 Intentional reimplantation (including splinting) 3910 Surgical procedure for isolation of tooth with rubber dam 3920 Hemisection (including root removal) 3950 Canal preparation and filling of preformed dowel or • post PERI000NTIC SERVICES 4210 Gingivectomy/gingivoplasly - 4 or more contiguous teeth per quad 4211 Gingivectomy/gingivoplasty -1 to 3 teeth, per quad 4220 Gingival curettage per quadrant (excluding root planing) 4240 Gingival flap procedure, including root planing - 4 or more 4241 Gingival flap procedure, including root planing - 1 to 3 teeth, per quad 4245 Apcally positioned flap 4249 Clinical crown lengthening - hard tissue 4260 Osseous surgery (including flap entry and closure) 4 or more contiguous teeth per quad 4261 Osseous surgery (induding lap entry and closure) 1 l0 3 teeth per quadrant 4263 Bone replacement graft- first sile in quadrant 4264 Bone replacement graft - each additional site in quadrant 4266 Guided tissue regeneration - resorbable barrier, per site No Charge No Charge 65.00 65.00 60.00 65.00 125.00 215.00 305.00 65.00 65.00 65.00 145.00 250.00 365.00 90.00 90.00 90.00 175.00 175.00 175.00 100.00 35.00 85.00 175.00 95.00 80.00 75.00 135.00 60.00 40.00 160.00 150.00 160.00 135.00 395.00 235.00 225.00 175.00 295.00 3 Int. CODE DESCRIPTION 4267 Guided tissue regeneration - nonresorbable barrier, per site 4270 Pedicle soft tissue graft procedure 4271 Free soft tissue graft procedure (including donor site surgery) 4273 Subepithelial 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 - 1 to 3 teeth, per quadrant 4355 Full mouth debridement to enable comprehensive evaluation and diagnosis 4381 Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth 4910 Periodontal maintenance 4920 Unscheduled dressing change (by someone other than the Treating dental office) PROSTHODONTICS- REMOVABLE 5110 Complete denture - maxillary 5120 Complete denture - mandibular 5130 Immediate denture - maxillary (including two relines) 5140 Immediate denture - mandibular (including two relines) 5211 Maxillary partial denture - resin base (including clasps) 5212 Mandibular partial denture - resin base (including clasps) 5213 Partial denture - maxillary cast metal - acrylic 5214 Partial denture - mandibular cast metal - acrylic 5281 Removable unilateral partial denture - one piece cast metal 5410 Adjustment - complete denture - maxillary 5411 Adjustment - complete denture - mandibular 5421 Adjustment - partial denture - maxillary 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 twelve (12) months are at No Charge) 5510 Repair broken complete denture base 5520 Replace broken tooth - complete denture (each tooth) 5610 Repair denture resin base 5620 Repair cast framework 5630 Repair or replace broken clasp 5640 Repair broken teeth - per tooth 5650 Add tooth to existing partial denture 5660 Add clasp to existing partial denture 5710 Rebase complete maxillary denture 5711 Rebase complete mandibular denture 5720 Rebase maxillary partial denture 5721 Rebase mandibular partial denture 5730 Reline complete maxillary denture (chairside) 5731 Reline complete mandibular denture (chairside) 5740 Reline partial maxillary denture (chairside) 5741 Reline partial mandibular denture (chairside) 5750 Reline complete maxillary denture (laboratory) 5751 Reline complete mandibular denlure (laboratory) 5760 Reline partial maxillary denture (laboratory) 5761 Reline partial mandibular denture (laboratory) 5810 Interim complete denture - maxillary 5811 Interim complete denture - mandibular 5820 Interim partial denture - maxillary 5821 Interim partial denture - mandibular 5850 Tissue conditioning - maxillary 5851 Tissue conditioning - mandibular 5862 Precision attachment 5899 Denture cleaning PROSTHODONTICS • FIXED 6210 Ponlic - cast high noble metal 6211 Ponlic - cast predominantly base metal 6212 Pontic - cast noble metal 6240 Pontic - porcelain fused to high noble metal 50.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 105.00 105.00 105,00 105.00 60.00 60.00 60.00 60.00 105.00 105.00 105.00 105.00 155,00 155.00 125.00 125.00 25.00 25.00 150.00 No Charge MEMBER CO -PAY CODE DESCRIPTION 335.00 6241 Ponlic - porcelain fused to predominantly base metal 225.00 6242 Ponlic - porcelain fused to noble metal 225.00 6245 Ponlic - porcelain/ceramic 280.00 6250 Pontic - resin with high noble metal 100.00 6251 Ponlic - resin with predominantly base metal 6252 Pontic - resin with noble metal 60.00 6545 Retainer - cast metal for resin bonded fixed prosthesis 35.00 6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis 60.00 6720 Crown - resin with high noble metal 6721 Crown - resin with predominantly base metal 60.00 6722 Crown - resin with noble metal 45.00 6740 Crown - porcelain/ceramic 6750 Crown - porcelain fused to high noble metal 20.00 6751 Crown - porcelain fused to predominantly base metal 6752 Crown - porcelain fused to noble metal 6780 Crown - 3/4 cast high noble metal 320.00 6781 Crown - 3/4 cast predominantly base metal 320.00 6782 Crown - 3/4 cast noble metal 320.00 6783 Crown - 3/4 porcelain/ceramic 320.00 6790 Crown - full cast high noble metal 290.00 6791 Crown - lull cast predominantly base metal 290.00 6792 Crown • full cast noble metal 360.00 6930 Recemenl fixed partial denture 360.00 6940 Stress breaker 6950 Precision attachment 330.00 6970 Cast post and core in addition to fixed partial 15.00 denture retainer 15.00 6971 Cast post as part of a fixed partial denture retainer 15.00 6972 Prefabricated post and core in addition to fixed partial 15.00 denture retainer 6973 Core build up for retainer, including pins 6975 Coping - metal 6976 Each additional cast post - same tooth 6977 Each additional prefabricated post - same tooth ORAL SURGERY 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 7260 0roantral fistula closure 7270 Tooth reimplantation 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 (all others) 7310 Alveoloplasty with extractions - per quadrant 7320 Alveoloplasly without extractions - per quadrant 7450 Removal of odonlogenic cyst or tumor up to 1.25 cm 7451 Removal of odonlogenic cyst or tumor greater than 1.25 cm 7510 Incision and drainage of abscess - inlraoral soft tissue 7960 Frenulectomy - separate procedure 7970 Excision of hyperplaslic tissue - per arch MISCELLANEOUS SERVICES 350.00 9215 Local anesthesia 280.00 9220 General anesthesia - first 30 minutes 340.00 9221 General anesthesia - each additional 15 minutes 350.00 9230 Analgesia nitrous oxide MEMBER C0-PAY 280.00 340.00 365.00 350.00 350.00 350.00 180.00 375.00 365.00 365.00 365.00 365.00 355.00 285.00 345.00 355.00 285.00 345.00 345.00 355.00 285.00 345.00 No Charge 125.00 125.00 125.00 105.00 30.00 25.00 95.00 75.00 75.00 45.00 No Charge 60.00 45.00 85.00 125.00 125.00 60.00 140.00 No Charge No Charge No Charge 95.00 75.00 65.00 85.00 No Charge No Charge No Charge No Charge 140.00 No Charge 115.00 60.00 20.00 per 1/2 hr 4' Int. CODE DESCRIPTION 9241 Intravenous sedation/analgesia - first 30 minutes 9242 Intravenous conscious sedation/analgesia - each additional 15 minutes 9630 Oral irrigation/other drugs/medicament 9910 Application of desensitizing medicament 9940 Occlusal guard 9950 Occlusal analysis - mounted case 9951 Occlusal adjustment - limited 9952 Occlusal adjustment - complete 9972 Cosmetic bleaching - per arch 9972 Cosmetic bleaching - both arches (Exduding bleaching material for home use) MEMBER CO -PAY 115.00 Emergency treatment is available for palliative treatment for the abatement of pain up to $100.00 per occurrence outside the service area (Florida). ORTHODONTIA 8660 Pre -orthodontic treatment visit 8999 Orthodontic treatment plan & records 8020 Limited orthodontic treatment of the transitional dentition (up to 24 months) 8030 Limited orthodontic treatment o1 the adolescent dentition (up to 24 months) 8040 Limited orthodontic treatment of the adult dentition (up to 24 months) 8070 Comprehensive orthodontic treatment of the transitional dentition (full treatment case up to 24 months - including fixedlremovable appliances) 8080 Comprehensive orthodontic treatment of the adolescent dentition (full Treatment case up to 24 months - including fixed/removable appliances) 0090 comprehensive orthodontic treatment of the adult dentition (full treatment case up l0 24 months - including fixed/removable appliances) 8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s) (includes fee for fixed/removable retainers and monthly visits) Orthodontic treatment is prorated over 24 months and is only payable under a current status. Prior written authorization is necessary for a referral to an orthodontist designated by Paragon. 60.00 15.00 2. per quadrant 20.00 3. 155.00 75.00 40.00 4. 120.00 150.00 5. 275.00 6. 7. 8. 40.00 9. 250.00 10. 11. 12. 1,850.00 13. 14. 15. 1,700.00 16. 2,300.00 17. 18. 300.00 19. 20. 21. 1,300.00 1,300.00 1,350.00 PARAGON SPECIALTY SERVICES 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 Thal are performed by a participating general dentist will be charged at the participating general dentist's usual and customary lee less 25%. 3. The participating general dentist you select may not perform all procedures listed. The co -payments shown 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 specialist (Oral Surgeon, Endodonlist, Orthodontist, Periodontist, Proslhodonlisl or Pedodontist) be necessary, you may receive this care in either of two ways: (1) You may go directly to a participating specialist with no referral and receive a 25% reduction off the providers usual and customary fee; or-(2) You may request specialty services 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 will be made to a designated speciaist. EXCLUSIONS/LIMITATIONS Any oral evaluation is limited to one (1) lime in any six (6) consecutive month period al no charge. All subsequent oral evaluations will be al a 25% discount olf the doctors usual and customary fee without a frequency limitation. Bilewing x-rays (2-4 films) are limited to one set in any twelve (12) consecutive month period. The dental prophylaxis or periodontal maintenance procedure is limited to one in any six (6) consecutive month period. Any additional procedures will follow 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 children under the age of 16. • Sealants are limited to one (1) lime per tooth in any Three (3) consecutive year period. This is only allowed for unrestored permanent molar teeth for children under the age of 16. Space maintainers and all adjustments are limited to children under the age of 16. Harmful habit appliances are limited to one (1) lime 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 andfor necessary for maintaining or improving the member's dental health, or experimental in nature, as determined by the participating Paragon dentist. Orthographic surgery or procedures and appliances for the treatment of myolundional, myoskeletal or temporomandibular 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, orescriplions, or medications. Treatment of malignancies, cysts, or neoplasms. Dental implants and related services. Dental procedures initiated prior to the member's eligibility under this benefit plan or started after the member's 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 including but not limited to physical or emotional resistance, inability 10 visit the dental office, or allergy to commonly utilized local anesthetics. New dentures include one (1) reline within the first six (6) months. Replacement of crowns, fixed bridges or dentures is limited 10 once every five (5) years. When crown and/or bridgework exceed six (6) consecutive units, there will be an additional charge of $30.00 per unit. Co -payments for endodontic procedures do not include the cost of the final restoration. Any fixed, restorative or removable prosthetic service may require additional costs to patient as follows: High noble metal (precious) up to $130.00 Noble metal (semi-precious) up to $110.00 Predominantly base metal (non -precious) up to $55.00 Crown laboratory fees up to $125.00 Laboratory tees on dentures up to $200.00 Porcelain laboratory fees for 2610 - 2644, 2962, 2740 up to $50.00 Denture repair laboratory fees up to $40.00 5 lnt.