Transcription
The following is MetLife’s Schedule of Benefits for the2021 Platinum (DHMO) plan in California
SCHEDULE OF BENEFITSBenefits provided by SafeGuard Health Plans, Inc., a MetLife companyDirect Referral Dental Plan*2021 METLIFEPLATINUM DHMOThis SCHEDULE OF BENEFITS lists the Covered Services available to You and Your Dependents under Yourdental plan, as well as Your and Your Dependent’s costs for each Covered Service. Your and YourDependent’s costs may include Co-Payments for a Covered Service.*Care under this plan is provided through a network of Selected General Dentists. Your Selected GeneralDentist is responsible for determining when the services of a Specialty Care Dentist are needed, andfacilitating any necessary referral. You and Your Dependents will be advised of the name, address andtelephone number of the Specialty Care Dentist in Your or Your Dependent’s Service Area.Missed Appointments: If You or Your Dependents need to cancel or reschedule an appointment, please notifythe Selected General Dental Office as far in advance as possible. This will allow the Selected General DentalOffice to accommodate another person in need of attention. If You or Your Dependents fail to do this in atimely fashion, You or Your Dependents may be charged a missed appointment fee. ServiceBroken Appointment (less than 24-hr notice)Office visit - per visit (including all fees for sterilization and/or infectioncontrol)Your and YourDependent’sCo-PaymentNot to exceed 25 5Your and c oral evaluation - established patient 0D0140Limited oral evaluation - problem focused 0D0145 0D0150Oral evaluation for a patient under three years of age and counseling withprimary caregiverComprehensive oral evaluation - new or established patientD0160Detailed and extensive oral evaluation - problem focused, by report 0D0170D0171Re-evaluation - limited, problem focused (established patient; not postoperative visit)Re-evaluation-post-operative office visit 0D0180Comprehensive periodontal evaluation - new or established patient 0D0190Screening of a patient 0D0191Assessment of a patient 0Diagnostic Treatment 0 0Radiographs / Diagnostic Imaging (X-rays)D0210Intraoral – complete series of radiographic images 0D0220Intraoral – periapical first radiographic image 0D0230Intraoral – periapical each additional radiographic image 0GCERT2010-DHMO-SOBsobCA (01/21)MET37641
SCHEDULE OF BENEFITS (continued)D0240D0250ServiceIntraoral – occlusal radiographic imageYour and YourDependent’sCo-Payment 0D0251Extra-oral – 2D projection radiographic image created using a stationaryradiation source, and detectorExtra-oral posterior dental radiographic image 0D0270Bitewing – single radiographic image 0D0272Bitewings – two radiographic images 0D0273Bitewings – three radiographic images 0D0274Bitewings – four radiographic images 0D0277Vertical bitewings – 7 to 8 radiographic images 0D0330Panoramic radiographic image 0D03402D cephalometric radiographic image – acquisition, measurement andanalysis2D oral/facial photographic image obtained intra-orally or extra-orally 1Cone beam CT capture and interpretation with limited field of view – less thanone whole jawCone beam CT capture and interpretation with field of view of one full dentalarch – mandibleCone beam CT capture and interpretation with field of view of one full dentalarch – maxilla, with or without craniumCone beam CT capture and interpretation with field of view of both jaws, withor without craniumCone beam CT image capture with limited field of view – less than one wholejawCone beam CT image capture with field of view of one full dental arch –mandibleCone beam CT image capture with field of view of one full dental arch –maxilla, with or without craniumCone beam CT image capture with field of view of both jaws, with or withoutcraniumInterpretation of diagnostic image by a practitioner not associated withcapture of the image, including reportTests and Examinations 0 0 180 180 180 180 180 180 180 180 0D0415Collection of microorganisms for culture and sensitivity 0D0425Caries susceptibility tests 0D0431 50D0460Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalitiesincluding premalignant and malignant lesions, not to include cytology orbiopsy proceduresPulp vitality testsD0470Diagnostic casts 0D0472Accession of tissue, gross examination, preparation and transmission ofwritten reportAccession of tissue, gross and microscopic examination, preparation andtransmission of written reportAccession of tissue, gross and microscopic examination, includingassessment of surgical margins for presence of disease, preparation andtransmission of written reportAccession of exfoliative cytologic smears, microscopic examination,D0473D0474D0480GCERT2010-DHMO-SOBsob 0 0 0 0 02
SCHEDULE OF BENEFITS (continued)Servicepreparation and transmission of written reportD0486D0502Laboratory accession of transepithelial cytologic sample, microscopicexamination, preparation and transmission of written reportOther oral pathology procedures, by reportYour and YourDependent’sCo-Payment 0 0Preventive ServicesD1110 D1120Removal of plaque, calculus and stains from the tooth structures and implantsin the permanent and transitional dentition. It is intended to control localirritational factors.Additional-adult prophylaxis (maximum of 2 additional per year) 0 35Removal of plaque, calculus and stains from the tooth structures and implantsin the primary and transitional dentition. It is intended to control localirritational factors.Additional-child prophylaxis (maximum of 2 additional per year) 25Topical application of fluoride varnish 0D1208Topical application of fluoride – excluding varnish 0D1310Nutritional counseling for control of dental disease 0D1320Tobacco counseling for the control and prevention of oral disease 0D1330Oral hygiene instructions 0 D1351Includes periodontal hygiene instruction D1206 0Sealant – per tooth 0 0D1353Preventive resin restoration in a moderate to high caries risk patient permanent toothSealant repair - per toothD1354Interim caries arresting medicament application – per tooth 0D1355Caries preventive medicament application – per tooth 0D1510 25D1516Space maintainer – fixed, unilateral – per quadrant Excludes a distal shoespace maintainer.Space maintainer – fixed – bilateral, maxillaryD1517Space maintainer – fixed – bilateral, mandibular 25D1520Space maintainer – removable, unilateral – per quadrant 35D1352 0 25D1526Space maintainer – removable – bilateral, maxillary 35D1527Space maintainer – removable – bilateral, mandibular 35D1551Re-cement or re-bond bilateral space maintainer – maxillary 5D1552Re-cement or re-bond bilateral space maintainer – mandibular 5D1553Re-cement or re-bond unilateral space maintainer – per quadrant 5D1556Removal of fixed unilateral space maintainer – per quadrant 5D1557Removal of fixed bilateral space maintainer - maxillary 5D1558Removal of fixed bilateral space maintainer - mandibular 5D1575Distal shoe space maintainer – fixed, unilateral – per quadrantFabrication and delivery of fixed appliance extending subgingivally anddistally to guide the eruption of the first permanent molar. Does not includeongoing follow-up or adjustments, or replacement appliance, once the toothhad erupted.Restorative TreatmentGCERT2010-DHMO-SOBsob 253
SCHEDULE OF BENEFITS (continued)Your and YourDependent’sCo-PaymentD2140ServiceAmalgam – one surface, primary or permanentD2150Amalgam – two surfaces, primary or permanent 0D2160Amalgam – three surfaces, primary or permanent 0D2161Amalgam – four or more surfaces, primary or permanent 0D2330Resin-based composite – one surface, anterior 0D2331Resin-based composite – two surfaces, anterior 0D2332Resin-based composite – three surfaces, anterior 0D2335Resin-based composite – four or more surfaces or involving incisal angle(anterior)Resin-based composite crown, anterior 0 30D2391Resin-based composite – one surface, posterior 30D2392Resin-based composite – two surfaces, posterior 45D2393Resin-based composite – three surfaces, posterior 65D2394Resin-based composite – four or more surfaces, posterior 65D2390 0Crowns D2510An additional charge, not to exceed 150 per unit, will be applied for anyprocedure using noble, high noble or titanium metal. There is a 75 CoPayment per molar, for the use of porcelain.Cases involving seven (7) or more Crowns, implants and/or fixed Bridge unitsin the same treatment plan require an additional 125 Co-Payment per unit inaddition to the specified Co-Payment for each Crown, implant or Bridge unit.Inlay – metallic – one surface 165D2520Inlay – metallic – two surfaces 165D2530Inlay – metallic – three or more surfaces 165D2542Onlay – metallic – two surfaces 185D2543Onlay – metallic – three surfaces 185 D2544Onlay – metallic – four or more surfaces 185D2610Inlay – porcelain/ceramic – one surface 185D2620Inlay – porcelain/ceramic – two surfaces 185D2630Inlay – porcelain/ceramic – three or more surfaces 185D2642Onlay – porcelain/ceramic – two surfaces 185D2643Onlay – porcelain/ceramic – three surfaces 185D2644Onlay – porcelain/ceramic – four or more surfaces 185D2650Inlay – resin-based composite – one surface 185D2651Inlay – resin-based composite – two surfaces 185D2652Inlay – resin-based composite – three or more surfaces 185D2662Onlay – resin-based composite – two surfaces 185D2663Onlay – resin-based composite – three surfaces 185D2664Onlay – resin-based composite – four or more surfaces 185D2710Crown – resin-based composite (indirect) 185D2712Crown – ¾ resin-based composite (indirect) 185D2720Crown – resin with high noble metal 185GCERT2010-DHMO-SOBsob4
SCHEDULE OF BENEFITS (continued)Your and YourDependent’sCo-PaymentD2721ServiceCrown – resin with predominantly base metalD2722Crown – resin with noble metal 185D2740Crown - porcelain/ceramic 225D2750Crown – porcelain fused to high noble metal 185D2751Crown – porcelain fused to predominantly base metal 185D2752Crown – porcelain fused to noble metal 185D2753Crown - porcelain fused to titanium and titanium alloys 185D2780Crown – ¾ cast high noble metal 185D2781Crown – ¾ cast predominantly base metal 185D2782Crown – ¾ cast noble metal 185D2783Crown – ¾ porcelain/ceramic 185D2790Crown – full cast high noble metal 185D2791Crown – full cast predominantly base metal 185D2792Crown – full cast noble metal 185D2794Crown - titanium and titanium alloys 185D2799 55D2910Provisional crown – further treatment or completion of diagnosis necessaryprior to final impressionRe-cement or re-bond inlay, onlay, veneer or partial coverage restorationD2915Re-cement or re-bond indirectly fabricated or prefabricated post and core 0D2920Re-cement or re-bond crown 0D2928Prefabricated porcelain/ceramic crown – permanent toothPrefabricated stainless steel crown – primary tooth 113D2930D2931Prefabricated stainless steel crown – permanent tooth 25D2932Prefabricated resin crown 35D2933Prefabricated stainless steel crown with resin window 35D2940Protective restoration 0D2941Interim therapeutic restoration - primary dentition 0D2950Core buildup, including any pins when required 50D2951Pin retention – per tooth, in addition to restoration 10D2952Post and core in addition to crown, indirectly fabricated 50D2953Each additional indirectly fabricated post – same tooth 50D2954Prefabricated post and core in addition to crown 30D2955Post removal 10D2957Each additional prefabricated post – same tooth 30D2960Labial veneer (resin laminate) – chairside 250D2961Labial veneer (resin laminate) – laboratory 300D2962Labial veneer (porcelain laminate) – laboratory 350D2971Additional procedures to construct new crown under existing partial dentureframeworkCrown repair necessitated by restorative material failure 50 0D2980 185 0 25D2981Inlay repair necessitated by restorative material failure 0D2982Onlay repair necessitated by restorative material failure 0GCERT2010-DHMO-SOBsob5
SCHEDULE OF BENEFITS (continued)Your and YourDependent’sCo-Payment 0D2983ServiceVeneer repair necessitated by restorative material failureD2990Resin infiltration of incipient smooth surface lesions D3110All procedures exclude final restoration.Pulp cap – direct (excluding final restoration) 0D3120Pulp cap – indirect (excluding final restoration) 0D3220Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronalto the dentinocemental junction and application of medicamentPulpal debridement, primary and permanent teeth 10 0EndodonticsD3221D3222 45D3310Partial pulpotomy for apexogenesis - permanent tooth with incomplete rootdevelopmentPulpal therapy (resorbable filling) – anterior, primary tooth (excluding finalrestoration)Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding finalrestoration)Endodontic therapy, anterior tooth (excluding final restoration)D3320Endodontic therapy, premolar tooth (excluding final restoration) 115D3330Endodontic therapy, molar tooth (excluding final restoration) 200D3331Treatment of root canal obstruction; non-surgical access 85D3332Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth 70D3333Internal root repair of perforation defects 85D3346Retreatment of previous root canal therapy – anterior 135D3347Retreatment of previous root canal therapy - premolar 175D3348Retreatment of previous root canal therapy – molar 275D3351Apexification/recalcification – initial visit (apical closure / calcific repair ofperforations, root resorption, etc.)Apexification/recalcification– interim medication replacement 65 65D3355Apexification/recalcification – final visit (includes completed root canal therapy– apical closure/calcific repair of perforations, root resorption, etc.)Pulpal regeneration - initial visit 65D3356Pulpal regeneration - interim medication replacement 35D3357Pulpal regeneration - completion of treatment 65D3410Apicoectomy – anterior 95D3421Apicoectomy - premolar (first root) 95D3425Apicoectomy – molar (first root) 95D3426Apicoectomy (each additional root) 60D3428Bone graft in conjunction with periradicular surgery - per tooth, single site 180D3429Bone graft in conjunction with periradicular surgery - each additionalcontiguous tooth in the same surgical siteRetrograde filling – per root 95D3230D3240D3352D3353D3430D3431D3432Biologic materials to aid in soft and osseous tissue regeneration inconjunction with periradicular surgeryGuided tissue regeneration, resorbable barrier, per site, in conjunction withperiradicular surgeryGCERT2010-DHMO-SOBsob 10 30 35 80 65 40 95 2156
SCHEDULE OF BENEFITS (continued)Your and YourDependent’sCo-PaymentD3450ServiceRoot amputation – per rootD3460Endodontic endosseous implant 555D3471Surgical repair of root resorption –anterior 72D3472Surgical repair of root resorption – premolar 72D3473Surgical repair of root resorption – molar 72D3501Surgical exposure of root surface without apicoectomy or repair of rootresorption – anteriorSurgical exposure of root surface without apicoectomy or repair of rootresorption – premolarSurgical exposure of root surface without apicoectomy or repair of rootresorption – molarSurgical procedure for isolation of tooth with rubber damD3502D3503D3910 95 53 53 53 0D3920Hemisection (including any root removal), not including root canal therapy 90D3950Canal preparation and fitting of preformed dowel or post 15Periodontics D4245Periodontal charting for planning treatment of periodontal disease is includedas part of overall diagnosis and treatment. No additional charge will apply toYou or Your Dependent or Us.Gingivectomy or gingivoplasty – four or more contiguous teeth or toothbounded spaces per quadrantGingivectomy or gingivoplasty – one to three contiguous teeth or toothbounded spaces per quadrantGingivectomy or gingivoplasty to allow access for restorative procedure, pertoothGingival flap procedure, including root planing – four or more contiguousteeth or tooth bounded spaces per quadrantGingival flap procedure, including root planing – one to three contiguous teethor tooth bounded spaces per quadrantApically positioned flapD4249Clinical crown lengthening – hard tissueD4260Osseous surgery (including elevation of a full thickness flap and closure) –four or more contiguous teeth or tooth bounded spaces per quadrantOsseous surgery (including elevation of a full thickness flap and closure) –one to three contiguous teeth or tooth bounded spaces per quadrantBone replacement graft – retained natural tooth – first site in quadrantD4210D4211D4212D4240D4241D4261D4263D4264 90 68 21 150 113 165 120 295 210 180 95D4265Bone replacement graft – retained natural tooth – each additional site inquadrantBiologic materials to aid in soft and osseous tissue regenerationD4266Guided tissue regeneration – resorbable barrier, per site 215D4267 255D4268Guided tissue regeneration – nonresorbable barrier, per site (includesmembrane removal)Surgical revision procedure, per toothD4270Pedicle soft tissue graft procedure 245D4273Autogenous connective tissue graft procedure (including donor and recipientsurgical sites) first tooth, implant, or edentulous tooth position in graftMesial/distal wedge procedure, single tooth (when not performed inconjunction with surgical procedures in the same anatomical area)D4274GCERT2010-DHMO-SOBsob 95 0 75 707
SCHEDULE OF BENEFITS iceNon-autogenous connective tissue graft (including recipient site and donormaterial) first tooth, implant, or edentulous tooth position in graftCombined connective tissue and double pedicle graft, per toothFree soft tissue graft procedure (including recipient and donor surgical sites)first tooth, implant or edentulous tooth position in graftFree soft tissue graft procedure (including recipient and donor surgical sites)each additional contiguous tooth, implant or edentulous tooth position insame graft siteAutogenous connective tissue graft procedure (including donor and recipientsurgical sites) – each additional contiguous tooth, implant or edentulous toothposition in same graft siteNon-autogenous connective tissue graft procedure (including recipientsurgical site and donor material) – each additional contiguous tooth, implantor edentulous tooth position in same graft siteProvisional splinting – intracoronalYour and YourDependent’sCo-Payment 380 75 245 123 38 190 95D4321Provisional splinting – extracoronal 85D4341Periodontal scaling and root planing – four or more teeth per quadrant 40D4342Periodontal scaling and root planing – one to three teeth per quadrant 30D4346Scaling in presence of generalized moderate or severe gingival inflammation– full mouth, after oral evaluationFull mouth debridement to enable a comprehensive oral evaluation anddiagnosis on a subsequent visitLocalized delivery of antimicrobial agents via controlled release vehicle intodiseased crevicular tissue, per toothPeriodontal maintenanceD4355D4381D4910D4920 Unscheduled dressing change (by someone other than treating dentist ortheir staff)Additional periodontal maintenance procedures (beyond 2 per 12 months) 0 40 60 30 0 55Removable Prosthodontics D5110Delivery of removable and fixed Prosthodontics includes up to 3 adjustmentswithin 6 months of delivery date of service.Complete denture – maxillary 210D5120Complete denture – mandibular 210D5130Immediate denture – maxillary 225D5140Immediate denture – mandibular 225D5211Maxillary partial denture – resin base (including, retentive/clasping materials,rests, and teeth)Mandibular partial denture – resin base (including, retentive/claspingmaterials, rests, and teeth)Maxillary partial denture - cast metal framework with resin denture bases(including retentive/clasping materials, rests and teeth)Mandibular partial denture - cast metal framework with resin denture bases(including retentive/clasping materials, rests and teeth)Immediate maxillary partial denture - resin base (including retentive/claspingmaterials, rests and teeth) Includes limited follow-up care only; does notinclude future rebasing/relining procedure(s).Immediate mandibular partial denture - resin base (includingretentive/clasping materials, rests and teeth) Includes limited follow-up careD5212D5213D5214D5221D5222GCERT2010-DHMO-SOBsob 240 240 260 260 240 2408
SCHEDULE OF BENEFITS (continued)Serviceonly; does not include future rebasing/relining procedure(s).D5223D5224D5225D5226Immediate maxillary partial denture - cast metal framework with resin denturebases (including retentive/clasping materials, rests and teeth) Includes limitedfollow-up care only; does not include future rebasing/relining procedure(s).Immediate mandibular partial denture - cast metal framework with resindenture bases (including retentive/clasping materials, rests and teeth)Includes limited follow-up care only; does not include future rebasing/reliningprocedure(s).Maxillary partial denture – flexible base (including any clasps, rests and teeth)Your and YourDependent’sCo-Payment 260 260 365D5410Mandibular partial denture – flexible base (including any clasps, rests andteeth)Removable unilateral partial denture – one piece cast metal (including claspsand teeth), maxillaryRemovable unilateral partial denture – one piece cast metal (including claspsand teeth), mandibularRemovable unilateral partial denture – one piece flexible base (includingclasps and teeth) – per quadrantRemovable unilateral partial denture – one piece resin (including clasps andteeth) – per quadrantAdjust complete denture – maxillaryD5411Adjust complete denture – mandibular 0D5421Adjust partial denture – maxillary 0D5422Adjust partial denture – mandibular 0D5511Repair broken complete denture base, mandibular 30D5512Repair broken complete denture base, maxillary 30D5520Replace missing or broken teeth – complete denture (each tooth) 30D5611Repair resin partial denture base, mandibular 30D5612Repair resin partial denture base, maxillary 30D5621Repair cast partial framework, mandibular 30D5622Repair cast partial framework, maxillary 30D5630Repair or replace broken retentive clasping materials – per tooth 35D5640Replace broken teeth – per tooth 30D5650Add tooth to existing partial denture 30D5660Add clasp to existing partial denture - per tooth 35D5670Replace all teeth and acrylic on cast metal framework (maxillary) 165D5282D5283D5284D5286 365 250 250 125 125 0D5671Replace all teeth and acrylic on cast metal framework (mandibular) 165D5710Rebase complete maxillary denture 60D5711Rebase complete mandibular denture 60D5720Rebase maxillary partial denture 60D5721Rebase mandibular partial denture 60D5730Reline complete maxillary denture (chairside) 35D5731Reline complete mandibular denture (chairside) 35D5740Reline maxillary partial denture (chairside) 35D5741Reline mandibular partial denture (chairside) 35GCERT2010-DHMO-SOBsob9
SCHEDULE OF BENEFITS (continued)Your and YourDependent’sCo-PaymentD5750ServiceReline complete maxillary denture (laboratory)D5751Reline complete mandibular denture (laboratory) 60D5760Reline maxillary partial denture (laboratory) 60D5761Reline mandibular partial denture (laboratory) 60D5810Interim complete denture (maxillary) 230D5811Interim complete denture (mandibular) 230D5820Interim partial denture (maxillary) 60D5821Interim partial denture (mandibular) 60D5850Tissue conditioning, maxillary 10D5851Tissue conditioning, mandibularD5862Precision attachment, by report 10 160D5876Add metal substructure to acrylic full denture (per arch) 53 60Implant ServicesPre-Surgical ServicesD6190Radiographic/surgical implant index, by report 130D6010Surgical placement of implant body: endosteal implantD6012D6013Surgical placement of interim implant body for transitional prosthesis:endosteal implantSurgical placement of mini implant 1,005D6040Surgical placement: eposteal implant 1,860D6050Surgical placement: transosteal implant 1,170D6051Interim abutmentD6096Remove broken implant retaining screw 123 24D6100Implant removal, by report 240D6101Debridement of a peri-implant defect or defects surrounding a single implant,and surface cleaning of the exposed implant surfaces, including flap entryand closureDebridement and osseous contouring of a peri-implant defect or defectssurrounding a single implant and includes surface cleaning of the exposedimplant surfaces, including flap entry and closureBone graft for repair of peri-implant defect – does not include flap entry andclosureBone graft at time of implant placement 34Surgical ServicesD6102D6103D6104 1,005 770 63 100 100Implant Supported Prosthetics An additional charge, not to exceed 150 per unit, will be applied for anyprocedure using noble, high noble or titanium metal. There is a 75 CoPayment per molar, for the use of porcelain. D6055Cases involving seven (7) or more Crowns, implants and/or fixed Bridge unitsin the same treatment plan require an additional 125 Co-Payment per unit inaddition to the specified Co-Payment for each Crown, implant or Bridge unit.Connecting bar – implant supported or abutment supported 345D6056Prefabricated abutment – includes modification and placement 245GCERT2010-DHMO-SOBsob10
SCHEDULE OF BENEFITS (continued)Your and YourDependent’sCo-PaymentD6057ServiceCustom fabricated abutment – includes placementD6058Abutment supported porcelain/ceramic crown 685D6059Abutment supported porcelain fused to metal crown (high noble metal) 660D6060 640D6061Abutment supported porcelain fused to metal crown (predominantly basemetal)Abutment supported porcelain fused to metal crown (noble metal)D6062Abutment supported cast metal crown (high noble metal) 655D6063Abutment supported cast metal crown (predominantly base metal) 640D6064Abutment supported cast metal crown (noble metal) 720D6065Implant supported porcelain/ceramic crown 725D6066Implant supported crown - porcelain fused to high noble alloys 700D6067A single metal-ceramic crown restoration that is retained, supported andstabilized by an implant.Abutment supported retainer for porcelain/ceramic FPD 725D6068D6069 335 645 680D6071Abutment supported retainer for porcelain fused to metal FPD (high noblemetal)Abutment supported retainer for porcelain fused to metal FPD (predominantlybase metal)Abutment supported retainer for porcelain fused to metal FPD (noble metal)D6072Abutment supported retainer for cast metal FPD (high noble metal) 625D6073Abutment supported retainer for cast metal FPD (predominantly base metal) 445D6074Abutment supported retainer for cast metal FPD (noble metal) 640D6075Implant supported retainer for ceramic FPD 720D6076D6082Implant supported retainer for FPD - porcelain fused to high noble alloys Ametal-ceramic retainer for a fixed partial denture that gains retention, supportand stability from an implant.Implant supported retainer for metal FPD - high noble alloys A metal retainerfor a fixed partial denture that gains retention, support and stability from animplant.Implant maintenance procedures when prostheses are removed andreinserted, including cleansing of prosthesis and abutmentsScaling and debridement in the presence of inflammation or mucositis of asingle implant, including cleaning of the implant surfaces, without flap entryand closureImplant supported crown – porcelain fused to predominantly base alloysD6083Implant supported crown – porcelain fused to noble alloys 645D6084Implant supported crown – porcelain fused to titanium and titanium alloys 650D6086Implant supported crown – predominantly base alloys 640D6087Implant supported crown – noble alloys 720D6088Implant supported crown – titanium and titanium alloys 650D6090Repair implant supported prosthesis, by report 190D6091 170D6092Replacement of semi-precision or precision attachment (male or femalecomponent) of implant/abutment supported prosthesis, per attachmentRe-cement or re-bond implant/abutment supported crownD6093Re-cement or re-bond implant/abutment supported fixed partial denture 70D6070D6077D6080D6081GCERT2010-DHMO-SOBsob 680 595 635 700 510 55 17 640 5011
SCHEDULE OF BENEFITS (continued)Your and YourDependent’sCo-PaymentD6095ServiceAbutment supported crown - titanium and titanium alloys A single crownrestoration that is retained, supported and stabilized by an abutment on animplant.Repair implant abutment, by reportD6097Abutment supported crown – porcelain fused to titanium and titanium alloys 700D6098Implant supported retainer – porcelain fused to predominantly base alloys 595D6099Implant supported retainer for FPD – porcelain fused to noble alloys 635D6110Implant/abutment supported removable denture for edentulous arch-maxillaryImplant/abutment supported removable denture for edentulous archmandibularImplant/abutment supported removable denture for partially edentulous archmaxillaryImplant/abutment supported removable denture for partially edentulous archmandibular 995D6094D6111D6112D6113 650 140 995 945 945 2,380D6114Implant/abutment supported fixed denture for edentulous arch-maxillaryD6115D6120Implant/abutment supported fixed denture for edentulous arch-mandibularImplant/abutment supported fixed denture for partially edentulous archmaxillaryImplant/abutment supported fixed denture for partially edentulous archmandibularImplant supported retainer – porcelain fused to titanium and titanium alloysD6121Implant supported retainer for metal FPD – predominantly base alloys 445D6122Implant supported retainer for metal FPD – predominantly base alloysD6123Implant supported retainer for metal FPD – noble alloys 640 520D6191Semi-precision abutment – placement 335D6192Semi-precision attachment – placement 252D6194Abutment supported retainer crown for FPD – titanium and titanium alloys. Aretainer for a fixed partial denture that gains retention, support and stabilityfrom an abutment on an implant.Abutment supported retainer – porcelain fused to titanium and titanium alloys 520D6116D6117D6195 2,380 1,410 1,410 520 510Crowns/Fixed Bridges - Per Unit An additional charge, not to exceed 150 per unit, will be ap
Direct Referral Dental Plan* 2021 METLIFE PLATINUM DHMO GCERT2010-DHMO-SOB CA (01/21) sob MET3764 1 This SCHEDULE OF BENEFITS lists the Covered Services available to You and Your Dependents under Your dental plan, as well as Your and Your Dependent's costs for each Covered Service. Your and Your Dependent's costs may include Co-Payments for .
