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FOOTNOTES |
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| 1 Base or noble metal is the benefit. If an inlay, onlay or indirectly fabricated post and core is made of high noble metal, an additional fee up to $100.00 per tooth will be charged for the upgrade.
2 Enrollee pays an additional copayment of $75.00 for placement on a molar.
3 Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials are material upgrades. The Contract Dentist may charge an additional fee not to exceed $325.00 in addition to the listed Copayment.
4 In the event orthodontic treatment is not required or is declined by the Enrollee, a fee of $85.00 will apply. The Enrollee is also responsible for any incurred orthodontic diagnostic record fees. |
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