36C24722Q0010.docx
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- Attached to
- Q503--DENTAL PROTHESIS Federal contract opportunity
- Solicitation number
- 36C24722Q0010
About this file
This is a solicitation for dental prosthesis laboratory services. The Department of Veterans Affairs is seeking a contractor to provide services including same-day relines, repairs, replacements, and acrylic partial dentures at the Ralph H. Johnson VA Medical Center in Charleston, South Carolina. The base period of performance is from October 1, 2021 through September 30, 2022, with four one-year option periods available for renewal. The solicitation is set aside for verified service-disabled veteran-owned small businesses. Offerors must be registered in the Systems for Award Management and Vendor Information Pages databases. The solicitation includes pricing for over 150 line items covering a range of dental prosthesis and laboratory services. Offers are due by September 27, 2021.
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|---|---|---|
| 36C24722Q0010 0001.docx | DOCX document |
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36C24722Q0010
PAGE 1 OF
1. REQUISITION NO.
2. CONTRACT NO.
3. AWARD/EFFECTIVE DATE
4. ORDER NO.
5. SOLICITATION NUMBER
6. SOLICITATION ISSUE DATE
a. NAME
b. TELEPHONE NO. (No Collect Calls)
8. OFFER DUE DATE/LOCAL
TIME
9.
ISSUED BY
CODE
10. THIS ACQUISITION IS
UNRESTRICTED OR
SET ASIDE:
% FOR:
SMALL BUSINESS
HUBZONE SMALL
BUSINESS
SERVICE-DISABLED
VETERAN-OWNED
SMALL BUSINESS
WOMEN-OWNED SMALL BUSINESS
(WOSB) ELIGIBLE UNDER THE
WOMEN-OWNED
SMALL BUSINESS PROGRAM
EDWOSB
8(A)
NAICS:
SIZE STANDARD:
11. DELIVERY FOR FOB DESTINA-
TION UNLESS BLOCK IS
MARKED
SEE SCHEDULE
12. DISCOUNT TERMS
13a. THIS CONTRACT IS A
RATED ORDER UNDER
DPAS (15
CFR 700)
13b. RATING
14. METHOD OF SOLICITATION
RFQ
IFB
RFP
15. DELIVER TO
CODE
16. ADMINISTERED BY
CODE
17a. CONTRACTOR/OFFEROR
CODE
FACILITY CODE
18a. PAYMENT WILL BE MADE BY
CODE
TELEPHONE NO.
DUNS:
DUNS+4:
PHONE:
FAX:
17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED
SEE ADDENDUM
19.
20.
21.
22.
23.
24.
ITEM NO.
SCHEDULE OF SUPPLIES/SERVICES
QUANTITY
UNIT
UNIT PRICE
AMOUNT
(Use Reverse and/or Attach Additional Sheets as Necessary)
25. ACCOUNTING AND APPROPRIATION DATA
26. TOTAL AWARD AMOUNT (For Govt. Use Only) 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA
ARE
ARE NOT ATTACHED.
27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA
ARE
ARE NOT ATTA
CHED
28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________
29. AWARD OF CONTRACT: REF. ___________________________________ OFFER
COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND
DATED ________________________________. YOUR OFFER ON SOLICITATION
DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY
(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE
ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED
SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:
30a. SIGNAT
URE OF OFFEROR/CONTRACTOR
31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER) 30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED
AUTHORIZED FOR LOCAL REPRODUCTION
(REV. 2/2012)
PREVIOUS EDITION IS NOT USABLE
Prescribed by GSA - FAR (48 CFR) 53.212
7. FOR SOLICITATION
INFORMATION CALL:
STANDARD FORM 1449
OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30
SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS
534-22-1-176-0001 36C24722Q0010 09-21-2021 Marcus Watts 334-725-3166 09-27-2021 1:00
CDT
Department of Veterans Affairs Central Alabama Veterans Health Care 215 Perry Hill Road Montgomery AL 36109-3798 X X 339116 500 Employees N/A X Department of Veteran Affairs Ralph H. Johnson VA Medical Center 109 Bee Street Charleston SC 29401-5799 Department of Veterans Affairs Central Alabama Health Care System East Campus 2400 Hospital Road Tuskegee AL 36083-5001
Department of Veterans Affairs
FMS-VA-2(101)
Financial Services Center PO Box 149971 Austin TX 78714-9971 See CONTINUATION Page Contractor shall provide Dental Prosthesis Lab Services for Charleston Va Medical Center.
This solicitation is set-aside for Veteran Owned Small Business (VOSB) ALl VOSB's need to be registered in WWW.SAMS.GOV and WWW.VIP.VETBIZ.VA.GOV.
See statement of work.
POP: DATE OF AWARD THROUGH ONE CALENDAR YEAR WITH FOUR ONE-
YEAR OPTIONS FOR RENEWAL.
See CONTINUATION Page x x x Michael Tempero Contra cting Officer Table of Contents
| SECTION A | 1 |
| A.1 SF 1449 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS | 1 |
| SECTION B - CONTINUATION OF SF 1449 BLOCKS | 3 |
| B.1 CONTRACT ADMINISTRATION DATA | 3 |
| B.2 PRICE/COST SCHEDULE | 9 |
| ITEM INFORMATION | 9 |
| SECTION C - CONTRACT CLAUSES | 84 |
| C.1 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998) | 84 |
| C.2 52.212-5 CONTRACT TERMS AND CONDITIONS REQUIRED TO IMPLEMENT STATUTES OR EXECUTIVE ORDERS—COMMERCIAL ITEMS (JAN 2021) (JUL 2020) (DEVIATION) | 84 |
| C.3 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999) | 92 |
| C.4 52.217-9 OPTION TO EXTEND THE TERM OF THE CONTRACT (MAR 2000) | 92 |
| C.5 VAAR 852.212-70 PROVISIONS AND CLAUSES APPLICABLE TO VA ACQUISITION OF COMMERCIAL ITEMS (APR 2020) | 92 |
| C.6 VAAR 852.219-74 LIMITATIONS ON SUBCONTRACTING—MONITORING AND COMPLIANCE (JUL 2018) | 94 |
| SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS | 96 |
| SECTION E - SOLICITATION PROVISIONS | 97 |
| E.1 52.212-1 INSTRUCTIONS TO OFFERORS—COMMERCIAL ITEMS (JUL 2021) | 97 |
| E.2 52.209-7 INFORMATION REGARDING RESPONSIBILITY MATTERS (OCT 2018) | 101 |
| E.3 52.217-5 EVALUATION OF OPTIONS (JUL 1990) | 102 |
| E.4 52.233-2 SERVICE OF PROTEST (SEP 2006) | 102 |
| E.5 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB 1998) | 103 |
| E.6 52.212-2 EVALUATION—COMMERCIAL ITEMS (OCT 2014) | 103 |
| E.7 52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS—COMMERCIAL ITEMS (FEB 2021) (JUL 2020) (DEVIATION) | 104 |
SECTION B - CONTINUATION OF SF 1449 BLOCKS
Left Blank Intentionally
B.1 CONTRACT ADMINISTRATION DATA
1. Contract Administration: All contract administration matters will be handled by the following individuals:
a. CONTRACTOR:
b. GOVERNMENT: Contracting Officer 36C247 Marcus Watts Department of Veterans Affairs Central Alabama Veterans Health Care
215 Perry Hill Road Montgomery AL 36109-3798
2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:
| [X] |
| 52.232-33, Payment by Electronic Funds Transfer—System For Award Management, or |
| [] |
| 52.232-36, Payment by Third Party |
3. INVOICES: Invoices shall be submitted in arrears:
| a. Quarterly | [] |
| b. Semi-Annually | [] |
| c. Other | [x] Monthly Upon Receipt of a Proper Invoice |
4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.
Department of Veterans Affairs
FMS-VA-2(101)
Financial Services Center PO Box 149971 Austin TX 78714-9971 ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:
| AMENDMENT NO |
| DATE |
DENTAL LAB SERVICES
Performance Based Work Statement
SERVICES: Contractor shall provide dental lab services 24 hours per day 7days per week and holiday coverage, the Contractor shall pick up twice daily, once in the morning and once in the afternoon and shall provide same day turnaround for all requested services. The Contractor shall provide services for: same day prosthetic relines, repair and replacement; same day acrylic partials and temporary treatment partials. The Contractor shall use Lucitone 199 high impact, Dental Diamond D Acrylic and Injectable Ivoclar in its processing to provide high tensile strength to the requested prosthetic. In addition, services related to digital dentistry is required to include (but not limited to): crowns, bridgework, surgical templates, implant supported prostheses, radiographic guides, as specified on the Listing of Services CLINS, for eligible dental patients of the Ralph H. Johnson Veterans Affairs Medical Center (VAMC), North Charleston Outpatient Clinic Charleston, 6450 Rivers Ave, North Charleston, SC. 29406.
General Requirements The contract shall furnish Monday through Friday between the hours of 7:30 A.M. and 4:00 P.M. local time, all labor, transportation, materials, general dental laboratory tools, equipment and supervision required to provide Dental Prostheses to the Ralph H. Johnson Veterans Affairs Medical Center (VAMC), North Charleston Outpatient Clinic Charleston, 6450 Rivers Ave, North Charleston, SC. 29406.
The contractor shall fabricate dental prosthetic items in strict accordance with the dental laboratory order for the fabrication of dental prostheses, which shall include but not be limited to the following: all laboratory fabrication aspects of complete dentures, removable partial dentures, and dental implant prosthesis.
Special handling may be required on specific orders and will be authorized on a case by case basis by the VAMC and paid for under a separate purchase order. (Brand name or Equal clause incorporated) The normal turnaround time (in working days as defined) for dental prosthetic items shall be:
a. Twenty-four hours:
Complete and Removable Partial Denture acrylic resin repairs Complete and Removable Partial Denture, tooth additions/repairs Removable Partial Denture, with wrought wire clasp retained by acrylic resin Custom impression trays Custom impression trays, altered cast impression cast Poured impressions Articulation of cast Cast duplications Fluoride application tray Occlusal Night-guard, vacuuform oral appliances
b. Forty-eight hours:
Complete and Removable Partial Denture, relines Complete and Removable Partial Denture, rebases Complete and Removable Partial Denture, record bases and occlusion rims Complete and Removable Partial Denture, record bases and occlusion rims, stabilized/processed Lab processed surgical, bone reduction guides Transitional Removable Partial Denture, processed Removable partial denture clasp repairs/replacement with casted or soldiered metal clasps
c. Three Working Days:
Diagnostic wax-up, four teeth or less Tooth Rearrangements, Complete and Removable Partial Dentures Cast Post and Core restorations Radiographic guides
d. Five Working Days:
Complete and Removable Partial Denture, process acrylic resin Oburator, process acrylic resin Tooth Arrangements, Complete and Removable Partial Dentures Occlusal Nite-guard, processed acrylic resin Diagnostic wax-up, five teeth or more Surgical templates for implants Complete denture frameworks Lab processed denture bases
e. Less than two weeks from receiving case:
RPD frameworks Implant supported cast meso/sub structures (Bars, etc)
f. Less than Three weeks from receiving case:
Conventional or Digitally scanned crowns Conventional or Digitally Scanned bridgework less than 7 units
g. Less than Four weeks from receiving case:
Digitally scanned bridgework 8 or mor units
The following materials shall be used in the fabrication of dental prostheses Complete Dentures/Removable Partial Dentures:
Lucitone 199 acrylic resin Color coloration or equivalent Occlusal Scheme:
Monoplane, linear Anatomic, full balanced with 22 degree posterior Lingualized, linear 33 degree/monoplane 30 rational Functional/rational Tooth material:
Trubyte TMIPN
Contractor shall provide the following services at the Ralph H. Johnson Veterans Affairs Medical Center (VAMC), North Charleston Outpatient Clinic Charleston, 6450 Rivers Ave, North Charleston, SC. 29406:
Forms for the authorization of work at their facility Once daily pickup and delivery Monday through Friday in the Ralph H. Johnson Veterans Affairs Medical Center (VAMC), North Charleston Outpatient Clinic Charleston, 6450 Rivers Ave, North Charleston, SC. 29406 to include but not limited to:
1. All impressions
2. All necessary procedures relating to prosthodontic care.
Contract shall consult with the appropriate Using Service at the VAMC regarding any specific dental laboratory order.
Qualifications, licenses and inspection of contractor The VISN 7 contracting officer reserves the right to thoroughly inspect and investigate the contractor’s and subcontractor’s facilities and other qualifications.
The contractor and all subcontractors’ facilities shall have all licenses and permits as required by local and state authorities. Current copies of these must be provided to the contracting officer upon request.
PERIOD OF PERFORMANCE: 1 October 2021 through September 30, 2022, with the option to extend the term of the contract with four more one-year option periods. No service shall be performed by the Contractor after September 30th of the base or option year that has been exercised. The Contracting Officer will submit a written modification to the contractor to authorize services after the specified above dates addressed to be NCC North Charleston Clinic, 6450 Rivers Ave, North Charleston, SC 29406.
CONTRACTOR QUALIFICATIONS: Attending Dental personnel assigned by the Contractor to perform the services covered by this contract shall be licensed in a State, Territory, or Commonwealth of the United States or the District of Columbia. The qualifications of such personnel shall also be subject to review by the VAMC Chief of Staff and approved by the VAMC Director.
Definitions VAMC: Veterans Affairs Medical Center Special Handling: Unusual circumstance may dictate the need for a dental order to be picked up specially, shipped and returned overnight, or processed within a shorter time frame.
Routine Handling: A dental laboratory work authorization that is usually performed and returned within a specified time frame.
Turn Around time (TAT): The length of elapsed time between pickup of the dental lab order by the contractor until the receipt of the complete order by VA Dental Service.
Using Service: Same as VA Dental Service COR: Contracting Officers Representative Dental Laboratory Services: Laboratory procedures required for the treatment of dental patients include, but are not limited to, all laboratory fabrication aspects of complete dentures, removable partial dentures, fixed partial dentures and crowns, and dental implant prosthesis.
Working Day: Any twenty-four-hour period of the typical administrative work week, i.e. Monday through Friday. For example, if the contract is allowed 5 working days for a prosthesis and he picks it up on Monday, it would be due back to the VA the following Monday. Federal holidays occurring M-F are not considered a working day.
Effective May 7, 2020 all individuals entering TVAMC (employees, patients, or visitors) will be required to wear a face covering.
All individuals entering TVAMC have the option to bring their own face covering. If individuals do not have a face covering, they will be provided one at the door to be used for the duration of their time on campus.
The face covering must cover the mouth and nose, fit snugly, and allow for breathing without restriction.
Individuals should wash their hands immediately after removing their face covering.
Information on face coverings from the CDC may be found here:
https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html
“Due to COVID19, all staff, trainees, Veterans, inpatient residents, and visitors are required to wear a face covering during their time at VA facilities.
BVAMC patients and visitors have the option to bring their own face covering or one will be provided when entering the facility.
Collection bins will be available at exits, and cloth face coverings will be laundered and re-distributed.
B.2 PRICE/COST SCHEDULE
ITEM INFORMATION
| ITEM NUMBER |
| DESCRIPTION OF SUPPLIES/SERVICES |
| QUANTITY |
| UNIT |
| UNIT PRICE |
| AMOUNT |
| 10.00 |
| EA |
| __________________ |
| __________________ |
D2630 DENTAL ONLAY PORC 3/MORE SUR
Contract Period: Base POP Begin: 10-01-2021 POP End: 09-30-2022
LOCAL STOCK NUMBER: VA247-16C0290
| 8.00 |
| EA |
| __________________ |
| __________________ |
D2644 DENTAL ONLAY PORC 4/MORE SUR
POP Begin: 10-01-2021
| 157.00 |
| EA |
| __________________ |
| __________________ |
D5520 REPLACE DENTURE TEETH COMPLT
| 38.00 |
| EA |
| __________________ |
| __________________ |
D5610 DENTURES REPAIR RESIN BASE
| 7.00 |
| EA |
| __________________ |
| __________________ |
D5630 REP PARTIAL DENTURE CLASP
| 83.00 |
| EA |
| __________________ |
| __________________ |
D5640 REPLACE PART DENTURE TEETH
| 78.00 |
| EA |
| __________________ |
| __________________ |
D5650 ADD TOOTH TO PARTIAL DENTURE
| 21.00 |
| EA |
| __________________ |
| __________________ |
D5660 ADD CLASP TO PARTIAL DENTURE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5670 REPLC TTH&ACRLC ON MTL FRMWK
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5671 REPLC TTH&ACRLC MANDIBULAR
| 6.00 |
| EA |
| __________________ |
| __________________ |
D5710 DENTURES REBASE CMPLT MAXIL
| 4.00 |
| EA |
| __________________ |
| __________________ |
D5711 DENTURES REBASE CMPLT MAND
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5720 DENTURES REBASE PART MAXILL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5721 DENTURES REBASE PART MANDBL
| 64.00 |
| EA |
| __________________ |
| __________________ |
D5750 DENTURE RELN CMPLT MAX LAB
| 35.00 |
| EA |
| __________________ |
| __________________ |
D5751 DENTURE RELN CMPLT MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
D5760 DENTURE RELN PART MAXIL LAB
| 12.00 |
| EA |
| __________________ |
| __________________ |
D5761 DENTURE RELN PART MAND LAB
| 67.00 |
| EA |
| __________________ |
| __________________ |
D5850 DENTURE TISS CONDITN MAXILL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5820 DENTURE INTERM PART MAXILL
| 29.00 |
| EA |
| __________________ |
| __________________ |
D5851 DENTURE TISS CONDTIN MANDBL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D5860 OVERDENTURE COMPLETE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5861 OVERDENTURE PARTIAL
| 10.00 |
| EA |
| __________________ |
| __________________ |
D5862 PRECISION ATTACHMENT
| 1.00 |
| EA |
| __________________ |
| __________________ |
D5932 POSTSURGICAL OBTURATOR
Defined: Synonymous terminology: obturator. A prosthesis which artificially replaces part or all of the maxilla and associated teeth, lost duet surgery, trauma or congenital defects. A definitive obturator is made when it is deemed that further tissue changes or recurrence of tumor are unlikely and a more permanent prosthetic rehabilitation can be achieved; it is intended for long term use.
Contract Period: Base
| 27.00 |
| EA |
| __________________ |
| __________________ |
D6055 Implant connecting bar
| 17.00 |
| EA |
| __________________ |
| __________________ |
D6057 CUSTOM ABUTMENT
| 9.00 |
| EA |
| __________________ |
| __________________ |
D6058 ABUTMENT SUPPORTED CROWN
| 8.00 |
| EA |
| __________________ |
| __________________ |
D6059 ABUTMENT SUPPORTED MTL CROWN
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6060 ABUTMENT SUPPORTED MTL CROWN
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6062 ABUTMENT SUPPORTED MTL CROWN
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6065 IMPLANT SUPPORTED CROWN
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6066 IMPLANT SUPPORTED MTL CROWN
| 4.00 |
| EA |
| __________________ |
| __________________ |
D6067 IMPLANT SUPPORTED MTL CROWN
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6068 ABUTMENT SUPPORTED RETAINER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6069 ABUTMENT SUPPORTED RETAINER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6070 ABUTMENT SUPPORTED RETAINER
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6080 IMPLANT MAINTENANCE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6090 REPAIR IMPLANT
| 11.00 |
| EA |
| __________________ |
| __________________ |
D6091 REPL SEMI/PRECISION ATTACH
| 4.00 |
| EA |
| __________________ |
| __________________ |
D6092 RECEMENT SUPP CROWN
| 13.00 |
| EA |
| __________________ |
| __________________ |
D6199 IMPLANT PROCEDURE
| 8.00 |
| EA |
| __________________ |
| __________________ |
D6210 PROSTHODONT HIGH NOBLE METAL
| 18.00 |
| EA |
| __________________ |
| __________________ |
D6240 BRIDGE PORCELAIN HIGH NOBLE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6245 BRIDGE PORCELAIN/CERAMIC
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6251 BRIDGE RESIN BASE METAL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6720 RETAIN CROWN RESIN W HI NBLE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6740 CROWN PORCELAIN/CERAMIC
| 67.00 |
| EA |
| __________________ |
| __________________ |
D6750 CROWN PORCELAIN HIGH NOBLE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6780 CROWN 3/4 HIGH NOBLE METAL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6781 CROWN 3/4 CAST BASED METAL
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6790 CROWN FULL HIGH NOBLE METAL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6792 CROWN FULL NOBLE METAL CAST
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6793 PROVISIONAL RETAINER CROWN
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6940 STRESS BREAKER
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6950 PRECISION ATTACHMENT
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6980 BRIDGE REPAIR
| 30.00 |
| EA |
| __________________ |
| __________________ |
D6999 FIXED PROSTHODONTIC PROC
| 8.00 |
| EA |
| __________________ |
| __________________ |
D7880 OCCLUSAL ORTHOTIC APPLIANCE
| 119.00 |
| EA |
| __________________ |
| __________________ |
D9940 DENTAL OCCLUSAL GUARD
| 1.00 |
| EA |
| __________________ |
| __________________ |
D9941 FABRICATION ATHLETIC GUARD
| 2.00 |
| EA |
| __________________ |
| __________________ |
D9942 REPAIR/RELINE OCCLUSAL GUARD
| 2.00 |
| EA |
| __________________ |
| __________________ |
D2710 CROWN RESIN-BASED INDIRECT
| 21.00 |
| EA |
| __________________ |
| __________________ |
D2740 CROWN PORCELAIN/CERAMIC SUBS
| 133.00 |
| EA |
| __________________ |
| __________________ |
D2750 CROWN PORCELAIN W/ H NOBLE M
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2751 CROWN PORCELAIN FUSED BASE M
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2752 CROWN PORCELAIN W/ NOBLE MET
| 95.00 |
| EA |
| __________________ |
| __________________ |
D2790 CROWN FULL CAST HIGH NOBLE M
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2792 CROWN FULL CAST NOBLE METAL
| 6.00 |
| EA |
| __________________ |
| __________________ |
D2799 PROVISIONAL CROWN
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2960 LAMINATE LABIAL VENEER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2961 LAB LABIAL VENEER RESIN
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2962 LAB LABIAL VENEER PORCELAIN
| 5.00 |
| EA |
| __________________ |
| __________________ |
D2970 TEMPORARY CROWN (FX TOOTH)
| 15.00 |
| EA |
| __________________ |
| __________________ |
D2980 CROWN REPAIR
| 67.00 |
| EA |
| __________________ |
| __________________ |
D5110 DENTURES COMPLETE MAXILLARY
| 52.00 |
| EA |
| __________________ |
| __________________ |
D5120 DENTURES COMPLETE MANDIBLE
| 16.00 |
| EA |
| __________________ |
| __________________ |
D5130 DENTURES IMMEDIAT MAXILLARY
| 6.00 |
| EA |
| __________________ |
| __________________ |
D5140 DENTURES IMMEDIAT MANDIBLE
| 71.00 |
| EA |
| __________________ |
| __________________ |
D5211 DENTURES MAXILL PART RESIN
| 66.00 |
| EA |
| __________________ |
| __________________ |
D5212 DENTURES MAND PART RESIN
| 36.00 |
| EA |
| __________________ |
| __________________ |
D5213 DENTURES MAXILL PART METAL
| 58.00 |
| EA |
| __________________ |
| __________________ |
D5214 DENTURES MANDIBL PART METAL
| 68.00 |
| EA |
| __________________ |
| __________________ |
D5225 MAXILLARY PART DENTURE FLEX
| 50.00 |
| EA |
| __________________ |
| __________________ |
D5226 MANDIBULAR PART DENTURE FLEX
| 45.00 |
| EA |
| __________________ |
| __________________ |
D5410 DENTURES ADJUST CMPLT MAXIL
| 39.00 |
| EA |
| __________________ |
| __________________ |
D5411 DENTURES ADJUST CMPLT MAND
| 47.00 |
| EA |
| __________________ |
| __________________ |
D5421 DENTURES ADJUST PART MAXILL
| 93.00 |
| EA |
| __________________ |
| __________________ |
D5422 DENTURES ADJUST PART MANDBL
| 8.00 |
| EA |
| __________________ |
| __________________ |
D5510 DENTUR REPR BROKEN COMPL BAS
| 10.00 |
| EA |
| __________________ |
| __________________ |
D2630 DENTAL ONLAY PORC 3/MORE SUR
Contract Period: Option 1 POP Begin: 10-01-2022 POP End: 09-30-2023
| 8.00 |
| EA |
| __________________ |
| __________________ |
D2644 DENTAL ONLAY PORC 4/MORE SUR
POP Begin: 10-01-2022
| 157.00 |
| EA |
| __________________ |
| __________________ |
D5520 REPLACE DENTURE TEETH COMPLT
| 38.00 |
| EA |
| __________________ |
| __________________ |
D5610 DENTURES REPAIR RESIN BASE
| 7.00 |
| EA |
| __________________ |
| __________________ |
D5630 REP PARTIAL DENTURE CLASP
| 83.00 |
| EA |
| __________________ |
| __________________ |
D5640 REPLACE PART DENTURE TEETH
| 78.00 |
| EA |
| __________________ |
| __________________ |
D5650 ADD TOOTH TO PARTIAL DENTURE
| 21.00 |
| EA |
| __________________ |
| __________________ |
D5660 ADD CLASP TO PARTIAL DENTURE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5670 REPLC TTH&ACRLC ON MTL FRMWK
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5671 REPLC TTH&ACRLC MANDIBULAR
| 6.00 |
| EA |
| __________________ |
| __________________ |
D5710 DENTURES REBASE CMPLT MAXIL
| 4.00 |
| EA |
| __________________ |
| __________________ |
D5711 DENTURES REBASE CMPLT MAND
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5720 DENTURES REBASE PART MAXILL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5721 DENTURES REBASE PART MANDBL
| 64.00 |
| EA |
| __________________ |
| __________________ |
D5750 DENTURE RELN CMPLT MAX LAB
| 35.00 |
| EA |
| __________________ |
| __________________ |
D5751 DENTURE RELN CMPLT MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
D5760 DENTURE RELN PART MAXIL LAB
| 12.00 |
| EA |
| __________________ |
| __________________ |
D5761 DENTURE RELN PART MAND LAB
| 67.00 |
| EA |
| __________________ |
| __________________ |
D5850 DENTURE TISS CONDITN MAXILL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5820 DENTURE INTERM PART MAXILL
| 29.00 |
| EA |
| __________________ |
| __________________ |
D5851 DENTURE TISS CONDTIN MANDBL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D5860 OVERDENTURE COMPLETE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5861 OVERDENTURE PARTIAL
| 10.00 |
| EA |
| __________________ |
| __________________ |
D5862 PRECISION ATTACHMENT
| 1.00 |
| EA |
| __________________ |
| __________________ |
D5932 POSTSURGICAL OBTURATOR
Defined: Synonymous terminology: obturator. A prosthesis which artificially replaces part or all of the maxilla and associated teeth, lost duet surgery, trauma or congenital defects. A definitive obturator is made when it is deemed that further tissue changes or recurrence of tumor are unlikely and a more permanent prosthetic rehabilitation can be achieved; it is intended for long term use.
Contract Period: Option 1
| 27.00 |
| EA |
| __________________ |
| __________________ |
D6055 Implant connecting bar
| 17.00 |
| EA |
| __________________ |
| __________________ |
D6057 CUSTOM ABUTMENT
| 9.00 |
| EA |
| __________________ |
| __________________ |
D6058 ABUTMENT SUPPORTED CROWN
| 8.00 |
| EA |
| __________________ |
| __________________ |
D6059 ABUTMENT SUPPORTED MTL CROWN
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6060 ABUTMENT SUPPORTED MTL CROWN
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6062 ABUTMENT SUPPORTED MTL CROWN
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6065 IMPLANT SUPPORTED CROWN
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6066 IMPLANT SUPPORTED MTL CROWN
| 4.00 |
| EA |
| __________________ |
| __________________ |
D6067 IMPLANT SUPPORTED MTL CROWN
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6068 ABUTMENT SUPPORTED RETAINER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6069 ABUTMENT SUPPORTED RETAINER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6070 ABUTMENT SUPPORTED RETAINER
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6080 IMPLANT MAINTENANCE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6090 REPAIR IMPLANT
| 11.00 |
| EA |
| __________________ |
| __________________ |
D6091 REPL SEMI/PRECISION ATTACH
| 4.00 |
| EA |
| __________________ |
| __________________ |
D6092 RECEMENT SUPP CROWN
| 13.00 |
| EA |
| __________________ |
| __________________ |
D6199 IMPLANT PROCEDURE
| 8.00 |
| EA |
| __________________ |
| __________________ |
D6210 PROSTHODONT HIGH NOBLE METAL
| 18.00 |
| EA |
| __________________ |
| __________________ |
D6240 BRIDGE PORCELAIN HIGH NOBLE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6245 BRIDGE PORCELAIN/CERAMIC
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6251 BRIDGE RESIN BASE METAL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6720 RETAIN CROWN RESIN W HI NBLE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6740 CROWN PORCELAIN/CERAMIC
| 67.00 |
| EA |
| __________________ |
| __________________ |
D6750 CROWN PORCELAIN HIGH NOBLE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6780 CROWN 3/4 HIGH NOBLE METAL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6781 CROWN 3/4 CAST BASED METAL
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6790 CROWN FULL HIGH NOBLE METAL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6792 CROWN FULL NOBLE METAL CAST
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6793 PROVISIONAL RETAINER CROWN
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6940 STRESS BREAKER
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6950 PRECISION ATTACHMENT
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6980 BRIDGE REPAIR
| 30.00 |
| EA |
| __________________ |
| __________________ |
D6999 FIXED PROSTHODONTIC PROC
| 8.00 |
| EA |
| __________________ |
| __________________ |
D7880 OCCLUSAL ORTHOTIC APPLIANCE
| 119.00 |
| EA |
| __________________ |
| __________________ |
D9940 DENTAL OCCLUSAL GUARD
| 1.00 |
| EA |
| __________________ |
| __________________ |
D9941 FABRICATION ATHLETIC GUARD
| 2.00 |
| EA |
| __________________ |
| __________________ |
D9942 REPAIR/RELINE OCCLUSAL GUARD
| 2.00 |
| EA |
| __________________ |
| __________________ |
D2710 CROWN RESIN-BASED INDIRECT
| 21.00 |
| EA |
| __________________ |
| __________________ |
D2740 CROWN PORCELAIN/CERAMIC SUBS
| 133.00 |
| EA |
| __________________ |
| __________________ |
D2750 CROWN PORCELAIN W/ H NOBLE M
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2751 CROWN PORCELAIN FUSED BASE M
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2752 CROWN PORCELAIN W/ NOBLE MET
| 95.00 |
| EA |
| __________________ |
| __________________ |
D2790 CROWN FULL CAST HIGH NOBLE M
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2792 CROWN FULL CAST NOBLE METAL
| 6.00 |
| EA |
| __________________ |
| __________________ |
D2799 PROVISIONAL CROWN
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2960 LAMINATE LABIAL VENEER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2961 LAB LABIAL VENEER RESIN
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2962 LAB LABIAL VENEER PORCELAIN
| 5.00 |
| EA |
| __________________ |
| __________________ |
D2970 TEMPORARY CROWN (FX TOOTH)
| 15.00 |
| EA |
| __________________ |
| __________________ |
D2980 CROWN REPAIR
| 67.00 |
| EA |
| __________________ |
| __________________ |
D5110 DENTURES COMPLETE MAXILLARY
| 52.00 |
| EA |
| __________________ |
| __________________ |
D5120 DENTURES COMPLETE MANDIBLE
| 16.00 |
| EA |
| __________________ |
| __________________ |
D5130 DENTURES IMMEDIAT MAXILLARY
| 6.00 |
| EA |
| __________________ |
| __________________ |
D5140 DENTURES IMMEDIAT MANDIBLE
| 71.00 |
| EA |
| __________________ |
| __________________ |
D5211 DENTURES MAXILL PART RESIN
| 66.00 |
| EA |
| __________________ |
| __________________ |
D5212 DENTURES MAND PART RESIN
| 36.00 |
| EA |
| __________________ |
| __________________ |
D5213 DENTURES MAXILL PART METAL
| 58.00 |
| EA |
| __________________ |
| __________________ |
D5214 DENTURES MANDIBL PART METAL
| 68.00 |
| EA |
| __________________ |
| __________________ |
D5225 MAXILLARY PART DENTURE FLEX
| 50.00 |
| EA |
| __________________ |
| __________________ |
D5226 MANDIBULAR PART DENTURE FLEX
| 45.00 |
| EA |
| __________________ |
| __________________ |
D5410 DENTURES ADJUST CMPLT MAXIL
| 39.00 |
| EA |
| __________________ |
| __________________ |
D5411 DENTURES ADJUST CMPLT MAND
| 47.00 |
| EA |
| __________________ |
| __________________ |
D5421 DENTURES ADJUST PART MAXILL
| 93.00 |
| EA |
| __________________ |
| __________________ |
D5422 DENTURES ADJUST PART MANDBL
| 8.00 |
| EA |
| __________________ |
| __________________ |
D5510 DENTUR REPR BROKEN COMPL BAS
| 10.00 |
| EA |
| __________________ |
| __________________ |
D2630 DENTAL ONLAY PORC 3/MORE SUR
Contract Period: Option 2 POP Begin: 10-01-2023 POP End: 09-30-2024
| 8.00 |
| EA |
| __________________ |
| __________________ |
D2644 DENTAL ONLAY PORC 4/MORE SUR
POP Begin: 10-01-2023
| 157.00 |
| EA |
| __________________ |
| __________________ |
D5520 REPLACE DENTURE TEETH COMPLT
| 38.00 |
| EA |
| __________________ |
| __________________ |
D5610 DENTURES REPAIR RESIN BASE
| 7.00 |
| EA |
| __________________ |
| __________________ |
D5630 REP PARTIAL DENTURE CLASP
| 83.00 |
| EA |
| __________________ |
| __________________ |
D5640 REPLACE PART DENTURE TEETH
| 78.00 |
| EA |
| __________________ |
| __________________ |
D5650 ADD TOOTH TO PARTIAL DENTURE
| 21.00 |
| EA |
| __________________ |
| __________________ |
D5660 ADD CLASP TO PARTIAL DENTURE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5670 REPLC TTH&ACRLC ON MTL FRMWK
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5671 REPLC TTH&ACRLC MANDIBULAR
| 6.00 |
| EA |
| __________________ |
| __________________ |
D5710 DENTURES REBASE CMPLT MAXIL
| 4.00 |
| EA |
| __________________ |
| __________________ |
D5711 DENTURES REBASE CMPLT MAND
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5720 DENTURES REBASE PART MAXILL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5721 DENTURES REBASE PART MANDBL
| 64.00 |
| EA |
| __________________ |
| __________________ |
D5750 DENTURE RELN CMPLT MAX LAB
| 35.00 |
| EA |
| __________________ |
| __________________ |
D5751 DENTURE RELN CMPLT MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
D5760 DENTURE RELN PART MAXIL LAB
| 12.00 |
| EA |
| __________________ |
| __________________ |
D5761 DENTURE RELN PART MAND LAB
| 67.00 |
| EA |
| __________________ |
| __________________ |
D5850 DENTURE TISS CONDITN MAXILL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5820 DENTURE INTERM PART MAXILL
| 29.00 |
| EA |
| __________________ |
| __________________ |
D5851 DENTURE TISS CONDTIN MANDBL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D5860 OVERDENTURE COMPLETE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5861 OVERDENTURE PARTIAL
| 10.00 |
| EA |
| __________________ |
| __________________ |
D5862 PRECISION ATTACHMENT
| 1.00 |
| EA |
| __________________ |
| __________________ |
D5932 POSTSURGICAL OBTURATOR
Defined: Synonymous terminology: obturator. A prosthesis which artificially replaces part or all of the maxilla and associated teeth, lost duet surgery, trauma or congenital defects. A definitive obturator is made when it is deemed that further tissue changes or recurrence of tumor are unlikely and a more permanent prosthetic rehabilitation can be achieved; it is intended for long term use.
Contract Period: Option 2
| 27.00 |
| EA |
| __________________ |
| __________________ |
D6055 Implant connecting bar
| 17.00 |
| EA |
| __________________ |
| __________________ |
D6057 CUSTOM ABUTMENT
| 9.00 |
| EA |
| __________________ |
| __________________ |
D6058 ABUTMENT SUPPORTED CROWN
| 8.00 |
| EA |
| __________________ |
| __________________ |
D6059 ABUTMENT SUPPORTED MTL CROWN
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6060 ABUTMENT SUPPORTED MTL CROWN
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6062 ABUTMENT SUPPORTED MTL CROWN
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6065 IMPLANT SUPPORTED CROWN
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6066 IMPLANT SUPPORTED MTL CROWN
| 4.00 |
| EA |
| __________________ |
| __________________ |
D6067 IMPLANT SUPPORTED MTL CROWN
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6068 ABUTMENT SUPPORTED RETAINER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6069 ABUTMENT SUPPORTED RETAINER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6070 ABUTMENT SUPPORTED RETAINER
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6080 IMPLANT MAINTENANCE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6090 REPAIR IMPLANT
| 11.00 |
| EA |
| __________________ |
| __________________ |
D6091 REPL SEMI/PRECISION ATTACH
| 4.00 |
| EA |
| __________________ |
| __________________ |
D6092 RECEMENT SUPP CROWN
| 13.00 |
| EA |
| __________________ |
| __________________ |
D6199 IMPLANT PROCEDURE
| 8.00 |
| EA |
| __________________ |
| __________________ |
D6210 PROSTHODONT HIGH NOBLE METAL
| 18.00 |
| EA |
| __________________ |
| __________________ |
D6240 BRIDGE PORCELAIN HIGH NOBLE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6245 BRIDGE PORCELAIN/CERAMIC
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6251 BRIDGE RESIN BASE METAL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6720 RETAIN CROWN RESIN W HI NBLE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6740 CROWN PORCELAIN/CERAMIC
| 67.00 |
| EA |
| __________________ |
| __________________ |
D6750 CROWN PORCELAIN HIGH NOBLE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6780 CROWN 3/4 HIGH NOBLE METAL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6781 CROWN 3/4 CAST BASED METAL
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6790 CROWN FULL HIGH NOBLE METAL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6792 CROWN FULL NOBLE METAL CAST
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6793 PROVISIONAL RETAINER CROWN
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6940 STRESS BREAKER
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6950 PRECISION ATTACHMENT
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6980 BRIDGE REPAIR
| 30.00 |
| EA |
| __________________ |
| __________________ |
D6999 FIXED PROSTHODONTIC PROC
| 8.00 |
| EA |
| __________________ |
| __________________ |
D7880 OCCLUSAL ORTHOTIC APPLIANCE
| 119.00 |
| EA |
| __________________ |
| __________________ |
D9940 DENTAL OCCLUSAL GUARD
| 1.00 |
| EA |
| __________________ |
| __________________ |
D9941 FABRICATION ATHLETIC GUARD
| 2.00 |
| EA |
| __________________ |
| __________________ |
D9942 REPAIR/RELINE OCCLUSAL GUARD
| 2.00 |
| EA |
| __________________ |
| __________________ |
D2710 CROWN RESIN-BASED INDIRECT
| 21.00 |
| EA |
| __________________ |
| __________________ |
D2740 CROWN PORCELAIN/CERAMIC SUBS
| 133.00 |
| EA |
| __________________ |
| __________________ |
D2750 CROWN PORCELAIN W/ H NOBLE M
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2751 CROWN PORCELAIN FUSED BASE M
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2752 CROWN PORCELAIN W/ NOBLE MET
| 95.00 |
| EA |
| __________________ |
| __________________ |
D2790 CROWN FULL CAST HIGH NOBLE M
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2792 CROWN FULL CAST NOBLE METAL
| 6.00 |
| EA |
| __________________ |
| __________________ |
D2799 PROVISIONAL CROWN
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2960 LAMINATE LABIAL VENEER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2961 LAB LABIAL VENEER RESIN
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2962 LAB LABIAL VENEER PORCELAIN
| 5.00 |
| EA |
| __________________ |
| __________________ |
D2970 TEMPORARY CROWN (FX TOOTH)
| 15.00 |
| EA |
| __________________ |
| __________________ |
D2980 CROWN REPAIR
| 67.00 |
| EA |
| __________________ |
| __________________ |
D5110 DENTURES COMPLETE MAXILLARY
| 52.00 |
| EA |
| __________________ |
| __________________ |
D5120 DENTURES COMPLETE MANDIBLE
| 16.00 |
| EA |
| __________________ |
| __________________ |
D5130 DENTURES IMMEDIAT MAXILLARY
| 6.00 |
| EA |
| __________________ |
| __________________ |
D5140 DENTURES IMMEDIAT MANDIBLE
| 71.00 |
| EA |
| __________________ |
| __________________ |
D5211 DENTURES MAXILL PART RESIN
| 66.00 |
| EA |
| __________________ |
| __________________ |
D5212 DENTURES MAND PART RESIN
| 36.00 |
| EA |
| __________________ |
| __________________ |
D5213 DENTURES MAXILL PART METAL
| 58.00 |
| EA |
| __________________ |
| __________________ |
D5214 DENTURES MANDIBL PART METAL
| 68.00 |
| EA |
| __________________ |
| __________________ |
D5225 MAXILLARY PART DENTURE FLEX
| 50.00 |
| EA |
| __________________ |
| __________________ |
D5226 MANDIBULAR PART DENTURE FLEX
| 45.00 |
| EA |
| __________________ |
| __________________ |
D5410 DENTURES ADJUST CMPLT MAXIL
| 39.00 |
| EA |
| __________________ |
| __________________ |
D5411 DENTURES ADJUST CMPLT MAND
| 47.00 |
| EA |
| __________________ |
| __________________ |
D5421 DENTURES ADJUST PART MAXILL
| 93.00 |
| EA |
| __________________ |
| __________________ |
D5422 DENTURES ADJUST PART MANDBL
| 8.00 |
| EA |
| __________________ |
| __________________ |
D5510 DENTUR REPR BROKEN COMPL BAS
| 10.00 |
| EA |
| __________________ |
| __________________ |
D2630 DENTAL ONLAY PORC 3/MORE SUR
Contract Period: Option 3 POP Begin: 10-01-2024 POP End: 09-30-2025
| 8.00 |
| EA |
| __________________ |
| __________________ |
D2644 DENTAL ONLAY PORC 4/MORE SUR
POP Begin: 10-01-2024
| 157.00 |
| EA |
| __________________ |
| __________________ |
D5520 REPLACE DENTURE TEETH COMPLT
| 38.00 |
| EA |
| __________________ |
| __________________ |
D5610 DENTURES REPAIR RESIN BASE
| 7.00 |
| EA |
| __________________ |
| __________________ |
D5630 REP PARTIAL DENTURE CLASP
| 83.00 |
| EA |
| __________________ |
| __________________ |
D5640 REPLACE PART DENTURE TEETH
| 78.00 |
| EA |
| __________________ |
| __________________ |
D5650 ADD TOOTH TO PARTIAL DENTURE
| 21.00 |
| EA |
| __________________ |
| __________________ |
D5660 ADD CLASP TO PARTIAL DENTURE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5670 REPLC TTH&ACRLC ON MTL FRMWK
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5671 REPLC TTH&ACRLC MANDIBULAR
| 6.00 |
| EA |
| __________________ |
| __________________ |
D5710 DENTURES REBASE CMPLT MAXIL
| 4.00 |
| EA |
| __________________ |
| __________________ |
D5711 DENTURES REBASE CMPLT MAND
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5720 DENTURES REBASE PART MAXILL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5721 DENTURES REBASE PART MANDBL
| 64.00 |
| EA |
| __________________ |
| __________________ |
D5750 DENTURE RELN CMPLT MAX LAB
| 35.00 |
| EA |
| __________________ |
| __________________ |
D5751 DENTURE RELN CMPLT MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
D5760 DENTURE RELN PART MAXIL LAB
| 12.00 |
| EA |
| __________________ |
| __________________ |
D5761 DENTURE RELN PART MAND LAB
| 67.00 |
| EA |
| __________________ |
| __________________ |
D5850 DENTURE TISS CONDITN MAXILL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5820 DENTURE INTERM PART MAXILL
| 29.00 |
| EA |
| __________________ |
| __________________ |
D5851 DENTURE TISS CONDTIN MANDBL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D5860 OVERDENTURE COMPLETE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5861 OVERDENTURE PARTIAL
| 10.00 |
| EA |
| __________________ |
| __________________ |
D5862 PRECISION ATTACHMENT
| 1.00 |
| EA |
| __________________ |
| __________________ |
D5932 POSTSURGICAL OBTURATOR
Defined: Synonymous terminology: obturator. A prosthesis which artificially replaces part or all of the maxilla and associated teeth, lost duet surgery, trauma or congenital defects. A definitive obturator is made when it is deemed that further tissue changes or recurrence of tumor are unlikely and a more permanent prosthetic rehabilitation can be achieved; it is intended for long term use.
Contract Period: Option 3
| 27.00 |
| EA |
| __________________ |
| __________________ |
D6055 Implant connecting bar
| 17.00 |
| EA |
| __________________ |
| __________________ |
D6057 CUSTOM ABUTMENT
| 9.00 |
| EA |
| __________________ |
| __________________ |
D6058 ABUTMENT SUPPORTED CROWN
| 8.00 |
| EA |
| __________________ |
| __________________ |
D6059 ABUTMENT SUPPORTED MTL CROWN
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6060 ABUTMENT SUPPORTED MTL CROWN
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6062 ABUTMENT SUPPORTED MTL CROWN
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6065 IMPLANT SUPPORTED CROWN
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6066 IMPLANT SUPPORTED MTL CROWN
| 4.00 |
| EA |
| __________________ |
| __________________ |
D6067 IMPLANT SUPPORTED MTL CROWN
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6068 ABUTMENT SUPPORTED RETAINER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6069 ABUTMENT SUPPORTED RETAINER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6070 ABUTMENT SUPPORTED RETAINER
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6080 IMPLANT MAINTENANCE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6090 REPAIR IMPLANT
| 11.00 |
| EA |
| __________________ |
| __________________ |
D6091 REPL SEMI/PRECISION ATTACH
| 4.00 |
| EA |
| __________________ |
| __________________ |
D6092 RECEMENT SUPP CROWN
| 13.00 |
| EA |
| __________________ |
| __________________ |
D6199 IMPLANT PROCEDURE
| 8.00 |
| EA |
| __________________ |
| __________________ |
D6210 PROSTHODONT HIGH NOBLE METAL
| 18.00 |
| EA |
| __________________ |
| __________________ |
D6240 BRIDGE PORCELAIN HIGH NOBLE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6245 BRIDGE PORCELAIN/CERAMIC
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6251 BRIDGE RESIN BASE METAL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6720 RETAIN CROWN RESIN W HI NBLE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6740 CROWN PORCELAIN/CERAMIC
| 67.00 |
| EA |
| __________________ |
| __________________ |
D6750 CROWN PORCELAIN HIGH NOBLE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6780 CROWN 3/4 HIGH NOBLE METAL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6781 CROWN 3/4 CAST BASED METAL
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6790 CROWN FULL HIGH NOBLE METAL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6792 CROWN FULL NOBLE METAL CAST
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6793 PROVISIONAL RETAINER CROWN
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6940 STRESS BREAKER
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6950 PRECISION ATTACHMENT
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6980 BRIDGE REPAIR
| 30.00 |
| EA |
| __________________ |
| __________________ |
D6999 FIXED PROSTHODONTIC PROC
| 8.00 |
| EA |
| __________________ |
| __________________ |
D7880 OCCLUSAL ORTHOTIC APPLIANCE
| 119.00 |
| EA |
| __________________ |
| __________________ |
D9940 DENTAL OCCLUSAL GUARD
| 1.00 |
| EA |
| __________________ |
| __________________ |
D9941 FABRICATION ATHLETIC GUARD
| 2.00 |
| EA |
| __________________ |
| __________________ |
D9942 REPAIR/RELINE OCCLUSAL GUARD
| 2.00 |
| EA |
| __________________ |
| __________________ |
D2710 CROWN RESIN-BASED INDIRECT
| 21.00 |
| EA |
| __________________ |
| __________________ |
D2740 CROWN PORCELAIN/CERAMIC SUBS
| 133.00 |
| EA |
| __________________ |
| __________________ |
D2750 CROWN PORCELAIN W/ H NOBLE M
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2751 CROWN PORCELAIN FUSED BASE M
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2752 CROWN PORCELAIN W/ NOBLE MET
| 95.00 |
| EA |
| __________________ |
| __________________ |
D2790 CROWN FULL CAST HIGH NOBLE M
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2792 CROWN FULL CAST NOBLE METAL
| 6.00 |
| EA |
| __________________ |
| __________________ |
D2799 PROVISIONAL CROWN
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2960 LAMINATE LABIAL VENEER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2961 LAB LABIAL VENEER RESIN
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2962 LAB LABIAL VENEER PORCELAIN
| 5.00 |
| EA |
| __________________ |
| __________________ |
D2970 TEMPORARY CROWN (FX TOOTH)
| 15.00 |
| EA |
| __________________ |
| __________________ |
D2980 CROWN REPAIR
| 67.00 |
| EA |
| __________________ |
| __________________ |
D5110 DENTURES COMPLETE MAXILLARY
| 52.00 |
| EA |
| __________________ |
| __________________ |
D5120 DENTURES COMPLETE MANDIBLE
| 16.00 |
| EA |
| __________________ |
| __________________ |
D5130 DENTURES IMMEDIAT MAXILLARY
| 6.00 |
| EA |
| __________________ |
| __________________ |
D5140 DENTURES IMMEDIAT MANDIBLE
| 71.00 |
| EA |
| __________________ |
| __________________ |
D5211 DENTURES MAXILL PART RESIN
| 66.00 |
| EA |
| __________________ |
| __________________ |
D5212 DENTURES MAND PART RESIN
| 36.00 |
| EA |
| __________________ |
| __________________ |
D5213 DENTURES MAXILL PART METAL
| 58.00 |
| EA |
| __________________ |
| __________________ |
D5214 DENTURES MANDIBL PART METAL
| 68.00 |
| EA |
| __________________ |
| __________________ |
D5225 MAXILLARY PART DENTURE FLEX
| 50.00 |
| EA |
| __________________ |
| __________________ |
D5226 MANDIBULAR PART DENTURE FLEX
| 45.00 |
| EA |
| __________________ |
| __________________ |
D5410 DENTURES ADJUST CMPLT MAXIL
| 39.00 |
| EA |
| __________________ |
| __________________ |
D5411 DENTURES ADJUST CMPLT MAND
| 47.00 |
| EA |
| __________________ |
| __________________ |
D5421 DENTURES ADJUST PART MAXILL
| 93.00 |
| EA |
| __________________ |
| __________________ |
D5422 DENTURES ADJUST PART MANDBL
| 8.00 |
| EA |
| __________________ |
| __________________ |
D5510 DENTUR REPR BROKEN COMPL BAS
| 10.00 |
| EA |
| __________________ |
| __________________ |
D2630 DENTAL ONLAY PORC 3/MORE SUR
Contract Period: Option 4 POP Begin: 10-01-2025 POP End: 09-30-2026
| 8.00 |
| EA |
| __________________ |
| __________________ |
D2644 DENTAL ONLAY PORC 4/MORE SUR
POP Begin: 10-01-2025
| 157.00 |
| EA |
| __________________ |
| __________________ |
D5520 REPLACE DENTURE TEETH COMPLT
| 38.00 |
| EA |
| __________________ |
| __________________ |
D5610 DENTURES REPAIR RESIN BASE
| 7.00 |
| EA |
| __________________ |
| __________________ |
D5630 REP PARTIAL DENTURE CLASP
| 83.00 |
| EA |
| __________________ |
| __________________ |
D5640 REPLACE PART DENTURE TEETH
| 78.00 |
| EA |
| __________________ |
| __________________ |
D5650 ADD TOOTH TO PARTIAL DENTURE
| 21.00 |
| EA |
| __________________ |
| __________________ |
D5660 ADD CLASP TO PARTIAL DENTURE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5670 REPLC TTH&ACRLC ON MTL FRMWK
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5671 REPLC TTH&ACRLC MANDIBULAR
| 6.00 |
| EA |
| __________________ |
| __________________ |
D5710 DENTURES REBASE CMPLT MAXIL
| 4.00 |
| EA |
| __________________ |
| __________________ |
D5711 DENTURES REBASE CMPLT MAND
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5720 DENTURES REBASE PART MAXILL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5721 DENTURES REBASE PART MANDBL
| 64.00 |
| EA |
| __________________ |
| __________________ |
D5750 DENTURE RELN CMPLT MAX LAB
| 35.00 |
| EA |
| __________________ |
| __________________ |
D5751 DENTURE RELN CMPLT MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
D5760 DENTURE RELN PART MAXIL LAB
| 12.00 |
| EA |
| __________________ |
| __________________ |
D5761 DENTURE RELN PART MAND LAB
| 67.00 |
| EA |
| __________________ |
| __________________ |
D5850 DENTURE TISS CONDITN MAXILL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D5820 DENTURE INTERM PART MAXILL
| 29.00 |
| EA |
| __________________ |
| __________________ |
D5851 DENTURE TISS CONDTIN MANDBL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D5860 OVERDENTURE COMPLETE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D5861 OVERDENTURE PARTIAL
| 10.00 |
| EA |
| __________________ |
| __________________ |
D5862 PRECISION ATTACHMENT
| 1.00 |
| EA |
| __________________ |
| __________________ |
D5932 POSTSURGICAL OBTURATOR
Defined: Synonymous terminology: obturator. A prosthesis which artificially replaces part or all of the maxilla and associated teeth, lost duet surgery, trauma or congenital defects. A definitive obturator is made when it is deemed that further tissue changes or recurrence of tumor are unlikely and a more permanent prosthetic rehabilitation can be achieved; it is intended for long term use.
Contract Period: Option 4
| 27.00 |
| EA |
| __________________ |
| __________________ |
D6055 Implant connecting bar
| 17.00 |
| EA |
| __________________ |
| __________________ |
D6057 CUSTOM ABUTMENT
| 9.00 |
| EA |
| __________________ |
| __________________ |
D6058 ABUTMENT SUPPORTED CROWN
| 8.00 |
| EA |
| __________________ |
| __________________ |
D6059 ABUTMENT SUPPORTED MTL CROWN
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6060 ABUTMENT SUPPORTED MTL CROWN
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6062 ABUTMENT SUPPORTED MTL CROWN
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6065 IMPLANT SUPPORTED CROWN
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6066 IMPLANT SUPPORTED MTL CROWN
| 4.00 |
| EA |
| __________________ |
| __________________ |
D6067 IMPLANT SUPPORTED MTL CROWN
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6068 ABUTMENT SUPPORTED RETAINER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6069 ABUTMENT SUPPORTED RETAINER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6070 ABUTMENT SUPPORTED RETAINER
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6080 IMPLANT MAINTENANCE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6090 REPAIR IMPLANT
| 11.00 |
| EA |
| __________________ |
| __________________ |
D6091 REPL SEMI/PRECISION ATTACH
| 4.00 |
| EA |
| __________________ |
| __________________ |
D6092 RECEMENT SUPP CROWN
| 13.00 |
| EA |
| __________________ |
| __________________ |
D6199 IMPLANT PROCEDURE
| 8.00 |
| EA |
| __________________ |
| __________________ |
D6210 PROSTHODONT HIGH NOBLE METAL
| 18.00 |
| EA |
| __________________ |
| __________________ |
D6240 BRIDGE PORCELAIN HIGH NOBLE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6245 BRIDGE PORCELAIN/CERAMIC
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6251 BRIDGE RESIN BASE METAL
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6720 RETAIN CROWN RESIN W HI NBLE
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6740 CROWN PORCELAIN/CERAMIC
| 67.00 |
| EA |
| __________________ |
| __________________ |
D6750 CROWN PORCELAIN HIGH NOBLE
| 2.00 |
| EA |
| __________________ |
| __________________ |
D6780 CROWN 3/4 HIGH NOBLE METAL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6781 CROWN 3/4 CAST BASED METAL
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6790 CROWN FULL HIGH NOBLE METAL
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6792 CROWN FULL NOBLE METAL CAST
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6793 PROVISIONAL RETAINER CROWN
| 1.00 |
| EA |
| __________________ |
| __________________ |
D6940 STRESS BREAKER
| 3.00 |
| EA |
| __________________ |
| __________________ |
D6950 PRECISION ATTACHMENT
| 6.00 |
| EA |
| __________________ |
| __________________ |
D6980 BRIDGE REPAIR
| 30.00 |
| EA |
| __________________ |
| __________________ |
D6999 FIXED PROSTHODONTIC PROC
| 8.00 |
| EA |
| __________________ |
| __________________ |
D7880 OCCLUSAL ORTHOTIC APPLIANCE
| 119.00 |
| EA |
| __________________ |
| __________________ |
D9940 DENTAL OCCLUSAL GUARD
| 1.00 |
| EA |
| __________________ |
| __________________ |
D9941 FABRICATION ATHLETIC GUARD
| 2.00 |
| EA |
| __________________ |
| __________________ |
D9942 REPAIR/RELINE OCCLUSAL GUARD
| 2.00 |
| EA |
| __________________ |
| __________________ |
D2710 CROWN RESIN-BASED INDIRECT
| 21.00 |
| EA |
| __________________ |
| __________________ |
D2740 CROWN PORCELAIN/CERAMIC SUBS
| 133.00 |
| EA |
| __________________ |
| __________________ |
D2750 CROWN PORCELAIN W/ H NOBLE M
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2751 CROWN PORCELAIN FUSED BASE M
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2752 CROWN PORCELAIN W/ NOBLE MET
| 95.00 |
| EA |
| __________________ |
| __________________ |
D2790 CROWN FULL CAST HIGH NOBLE M
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2792 CROWN FULL CAST NOBLE METAL
| 6.00 |
| EA |
| __________________ |
| __________________ |
D2799 PROVISIONAL CROWN
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2960 LAMINATE LABIAL VENEER
| 1.00 |
| EA |
| __________________ |
| __________________ |
D2961 LAB LABIAL VENEER RESIN
| 7.00 |
| EA |
| __________________ |
| __________________ |
D2962 LAB LABIAL VENEER PORCELAIN
| 5.00 |
| EA |
| __________________ |
| __________________ |
D2970 TEMPORARY CROWN (FX TOOTH)
| 15.00 |
| EA |
| __________________ |
| __________________ |
D2980 CROWN REPAIR
| 67.00 |
| EA |
| __________________ |
| __________________ |
D5110 DENTURES COMPLETE MAXILLARY
| 52.00 |
| EA |
| __________________ |
| __________________ |
D5120 DENTURES COMPLETE MANDIBLE
| 16.00 |
| EA |
| __________________ |
| __________________ |
D5130 DENTURES IMMEDIAT MAXILLARY
| 6.00 |
| EA |
| __________________ |
| __________________ |
D5140 DENTURES IMMEDIAT MANDIBLE
| 71.00 |
| EA |
| __________________ |
| __________________ |
D5211 DENTURES MAXILL PART RESIN
| 66.00 |
| EA |
| __________________ |
| __________________ |
D5212 DENTURES MAND PART RESIN
| 36.00 |
| EA |
| __________________ |
| __________________ |
D5213 DENTURES MAXILL PART METAL
| 58.00 |
| EA |
| __________________ |
| __________________ |
D5214 DENTURES MANDIBL PART METAL
| 68.00 |
| EA |
| __________________ |
| __________________ |
D5225 MAXILLARY PART DENTURE FLEX
| 50.00 |
| EA |
| __________________ |
| __________________ |
D5226 MANDIBULAR PART DENTURE FLEX
| 45.00 |
| EA |
| __________________ |
| __________________ |
D5410 DENTURES ADJUST CMPLT MAXIL
| 39.00 |
| EA |
| __________________ |
| __________________ |
D5411 DENTURES ADJUST CMPLT MAND
| 47.00 |
| EA |
| __________________ |
| __________________ |
D5421 DENTURES ADJUST PART MAXILL
| 93.00 |
| EA |
This is the start of the file's text. The full file is on GovTribe.
File details come from the government source that posted it. Updated .