Line Items.docx
DOCX document 115 KB Posted
- Attached to
- Dental Lab Services - Charleston SC
- Solicitation number
- 36C24726Q0843
About this file
This is a pricing template document for dental laboratory services required by the Ralph H. Johnson VA Healthcare System in Charleston, South Carolina. The document contains 91 line items organized into five contract periods: a base year and four option years. Each line item specifies a quantity in "each" (EA) units but leaves the unit price and total amount columns blank for bidder completion. The services encompass a comprehensive range of prosthodontic and restorative dental procedures, including crowns in various materials (porcelain/ceramic, high noble metal, noble metal, full cast), dentures (complete and partial in multiple configurations and materials), repairs and adjustments to dentures, pontics, retainers, implant-supported restorations, precision and semiprecision attachments, guided tissue regeneration, and specialized appliances such as occlusal guards and sleep apnea devices. Quantities per line item range from 5 to 460 units across the various procedures. The base year contains identical line items to the three option years, with item numbers prefixed 0001-0091 for the base year and 1001-1091, 2001-2091, 3001-3091, and 4001-4091 for option years one through four respectively. Bidders are required to provide pricing for all line items across all contract periods to complete the solicitation response. The document includes summary total rows after each contract period for cumulative pricing calculations.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24726Q0843 0001.docx | DOCX document | |
| Vendor Questions and Answers.docx | DOCX document | |
| 36C24726Q0843_Amended01.pdf | ||
| 36C24726Q0843.pdf | ||
| 36C24726Q0843.pdf |
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Text version
ITEM NUMBER
| DESCRIPTION OF SUPPLIES/SERVICES |
| QUANTITY |
| UNIT |
| UNIT PRICE |
| AMOUNT |
| 500.00 |
| EA |
| __________________ |
| __________________ |
CROWN PORCELAIN/CERAMIC SUBS
| 100.00 |
| EA |
| __________________ |
| __________________ |
CROWN PORCELAIN W/ H NOBLE M
| 100.00 |
| EA |
| __________________ |
| __________________ |
CROWN FULL CAST HIGH NOBLE M
| 35.00 |
| EA |
| __________________ |
| __________________ |
CROWN FULL CAST NOBLE METAL
| 80.00 |
| EA |
| __________________ |
| __________________ |
POST AND CORE CAST + CROWN
| 50.00 |
| EA |
| __________________ |
| __________________ |
PREFAB POST/CORE + CROWN
| 135.00 |
| EA |
| __________________ |
| __________________ |
UNSPECIFIED PERIODONTAL PROC
| 170.00 |
| EA |
| __________________ |
| __________________ |
DENTURES COMPLETE MAXILLARY
| 75.00 |
| EA |
| __________________ |
| __________________ |
DENTURES COMPLETE MANDIBLE
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENTURES IMMEDIAT MAXILLARY
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES IMMEDIAT MANDIBLE
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAXILL PART RESIN
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAND PART RESIN
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAXILL PART METAL
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MANDIBL PART METAL
| 25.00 |
| EA |
| __________________ |
| __________________ |
DENT IMMED MAXILL PART RESIN
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENT IMMED MAND PART RESIN
| 50.00 |
| EA |
| __________________ |
| __________________ |
MAXILLARY PART DENTURE FLEX
| 50.00 |
| EA |
| __________________ |
| __________________ |
MANDIBULAR PART DENTURE FLEX
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST CMPLT MAXIL
| 80.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST CMPLT MAND
| 110.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST PART MAXILL
| 125.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST PART MANDBL
| 60.00 |
| EA |
| __________________ |
| __________________ |
REPAIR DENTUR BASE CMPL MAND
| 80.00 |
| EA |
| __________________ |
| __________________ |
REPAIR DENTUR BASE CMPL MAX
| 100.00 |
| EA |
| __________________ |
| __________________ |
REPLACE DENTURE TEETH COMPLT
| 30.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL BASE MAND
| 35.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL BASE MAX
| 5.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL FRAMEW MAND
| 65.00 |
| EA |
| __________________ |
| __________________ |
REP PARTIAL DENTURE CLASP
| 100.00 |
| EA |
| __________________ |
| __________________ |
REPLACE PART DENTURE TEETH
| 100.00 |
| EA |
| __________________ |
| __________________ |
ADD TOOTH TO PARTIAL DENTURE
| 30.00 |
| EA |
| __________________ |
| __________________ |
ADD CLASP TO PARTIAL DENTURE
| 5.00 |
| EA |
| __________________ |
| __________________ |
DENTURES REBASE CMPLT MAXIL
| 5.00 |
| EA |
| __________________ |
| __________________ |
DENTURES REBASE CMPLT MAND
| 35.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAXIL CH
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAND CHR
| 55.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAXIL CHR
| 60.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAND CHR
| 55.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAX LAB
| 30.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAXIL LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
PART CMPLT SOFT RELN LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM CMPLT MAXILL
| 75.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM CMPLT MANDBL
| 60.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM PART MAXILL
| 120.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM PART MANDBL
| 130.00 |
| EA |
| __________________ |
| __________________ |
DENTURE TISS CONDITN MAXILL
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURE TISS CONDTIN MANDBL
| 5.00 |
| EA |
| __________________ |
| __________________ |
PRECISION ATTACHMENT REMOV
| 10.00 |
| EA |
| __________________ |
| __________________ |
OVERDENTURE PARTIAL MAX
| 15.00 |
| EA |
| __________________ |
| __________________ |
OVERDENTURE COMPLETE MAND
| 120.00 |
| EA |
| __________________ |
| __________________ |
REPLACEMENT OF PRECISION ATT
| 40.00 |
| EA |
| __________________ |
| __________________ |
PROSTHESIS MODIFICATION
| 300.00 |
| EA |
| __________________ |
| __________________ |
CUSTOM ABUTMENT
| 150.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN PORC/CER
| 15.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN PORC HNOB
| 30.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN ALL HNOB
| 20.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN ALL NOBL
| 115.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN PORC/CER
| 10.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN PORC MTL
| 15.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN ALL MTL
| 10.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT RETAIN PORC/CER
| 15.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT RETAIN PORC/CER
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT RETAIN PORC MTL
| 50.00 |
| EA |
| __________________ |
| __________________ |
GUIDED TISS REGEN RESORBLE
| 25.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV DENT MAX
| 25.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV DENT MAN
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV PRTL MAX
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV PRTL MAN
| 100.00 |
| EA |
| __________________ |
| __________________ |
RADIO/SURGICAL IMPLANT INDEX
| 100.00 |
| EA |
| __________________ |
| __________________ |
SEMIPRECISION ABUT
| 200.00 |
| EA |
| __________________ |
| __________________ |
SEMIPRECISION ATTACHMENT
| 15.00 |
| EA |
| __________________ |
| __________________ |
PONTIC HIGH NOBLE METAL
| 60.00 |
| EA |
| __________________ |
| __________________ |
PONTIC NOBLE METAL CAST
| 40.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN HIGH NOBLE
| 140.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN NOBLE METAL
| 115.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN/CERAMIC
| 100.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCELAIN/CERAMIC
| 70.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCLN HIGH NOBLE
| 15.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCLN NOBLE METAL
| 20.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN FULL HIGH NOBLE
| 20.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN FULL NOBLE METAL
| 460.00 |
| EA |
| __________________ |
| __________________ |
FIXED PROSTHODONTIC PROC
| 30.00 |
| EA |
| __________________ |
| __________________ |
FABRICATION ATHLETIC GUARD
| 35.00 |
| EA |
| __________________ |
| __________________ |
ADJUST OCCLUSAL GUARD
| 300.00 |
| EA |
| __________________ |
| __________________ |
OCCLUSAL GUARD HARD
| 45.00 |
| EA |
| __________________ |
| __________________ |
OCCLUSAL GUARD SOFT
| 180.00 |
| EA |
| __________________ |
| __________________ |
CUSTOM SLEEP APNEA APPLIANCE
| 25.00 |
| EA |
| __________________ |
| __________________ |
ADJ CUSTOM SLEEP APNEA APPL
BASE YEAR TOTAL
| 500.00 |
| EA |
| __________________ |
| __________________ |
CROWN PORCELAIN/CERAMIC SUBS
| 100.00 |
| EA |
| __________________ |
| __________________ |
CROWN PORCELAIN W/ H NOBLE M
| 100.00 |
| EA |
| __________________ |
| __________________ |
CROWN FULL CAST HIGH NOBLE M
| 35.00 |
| EA |
| __________________ |
| __________________ |
CROWN FULL CAST NOBLE METAL
| 80.00 |
| EA |
| __________________ |
| __________________ |
POST AND CORE CAST + CROWN
| 50.00 |
| EA |
| __________________ |
| __________________ |
PREFAB POST/CORE + CROWN
| 135.00 |
| EA |
| __________________ |
| __________________ |
UNSPECIFIED PERIODONTAL PROC
| 170.00 |
| EA |
| __________________ |
| __________________ |
DENTURES COMPLETE MAXILLARY
| 75.00 |
| EA |
| __________________ |
| __________________ |
DENTURES COMPLETE MANDIBLE
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENTURES IMMEDIAT MAXILLARY
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES IMMEDIAT MANDIBLE
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAXILL PART RESIN
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAND PART RESIN
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAXILL PART METAL
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MANDIBL PART METAL
| 25.00 |
| EA |
| __________________ |
| __________________ |
DENT IMMED MAXILL PART RESIN
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENT IMMED MAND PART RESIN
| 50.00 |
| EA |
| __________________ |
| __________________ |
MAXILLARY PART DENTURE FLEX
| 50.00 |
| EA |
| __________________ |
| __________________ |
MANDIBULAR PART DENTURE FLEX
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST CMPLT MAXIL
| 80.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST CMPLT MAND
| 110.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST PART MAXILL
| 125.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST PART MANDBL
| 60.00 |
| EA |
| __________________ |
| __________________ |
REPAIR DENTUR BASE CMPL MAND
| 80.00 |
| EA |
| __________________ |
| __________________ |
REPAIR DENTUR BASE CMPL MAX
| 100.00 |
| EA |
| __________________ |
| __________________ |
REPLACE DENTURE TEETH COMPLT
| 30.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL BASE MAND
| 35.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL BASE MAX
| 5.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL FRAMEW MAND
| 65.00 |
| EA |
| __________________ |
| __________________ |
REP PARTIAL DENTURE CLASP
| 100.00 |
| EA |
| __________________ |
| __________________ |
REPLACE PART DENTURE TEETH
| 100.00 |
| EA |
| __________________ |
| __________________ |
ADD TOOTH TO PARTIAL DENTURE
| 30.00 |
| EA |
| __________________ |
| __________________ |
ADD CLASP TO PARTIAL DENTURE
| 5.00 |
| EA |
| __________________ |
| __________________ |
DENTURES REBASE CMPLT MAXIL
| 5.00 |
| EA |
| __________________ |
| __________________ |
DENTURES REBASE CMPLT MAND
| 35.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAXIL CH
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAND CHR
| 55.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAXIL CHR
| 60.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAND CHR
| 55.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAX LAB
| 30.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAXIL LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
PART CMPLT SOFT RELN LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM CMPLT MAXILL
| 75.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM CMPLT MANDBL
| 60.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM PART MAXILL
| 120.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM PART MANDBL
| 130.00 |
| EA |
| __________________ |
| __________________ |
DENTURE TISS CONDITN MAXILL
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURE TISS CONDTIN MANDBL
| 5.00 |
| EA |
| __________________ |
| __________________ |
PRECISION ATTACHMENT REMOV
| 10.00 |
| EA |
| __________________ |
| __________________ |
OVERDENTURE PARTIAL MAX
| 15.00 |
| EA |
| __________________ |
| __________________ |
OVERDENTURE COMPLETE MAND
| 120.00 |
| EA |
| __________________ |
| __________________ |
REPLACEMENT OF PRECISION ATT
| 40.00 |
| EA |
| __________________ |
| __________________ |
PROSTHESIS MODIFICATION
| 300.00 |
| EA |
| __________________ |
| __________________ |
CUSTOM ABUTMENT
| 150.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN PORC/CER
| 15.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN PORC HNOB
| 30.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN ALL HNOB
| 20.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN ALL NOBL
| 115.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN PORC/CER
| 10.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN PORC MTL
| 15.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN ALL MTL
| 10.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT RETAIN PORC/CER
| 15.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT RETAIN PORC/CER
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT RETAIN PORC MTL
| 50.00 |
| EA |
| __________________ |
| __________________ |
GUIDED TISS REGEN RESORBLE
| 25.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV DENT MAX
| 25.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV DENT MAN
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV PRTL MAX
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV PRTL MAN
| 100.00 |
| EA |
| __________________ |
| __________________ |
RADIO/SURGICAL IMPLANT INDEX
| 100.00 |
| EA |
| __________________ |
| __________________ |
SEMIPRECISION ABUT
| 200.00 |
| EA |
| __________________ |
| __________________ |
SEMIPRECISION ATTACHMENT
| 15.00 |
| EA |
| __________________ |
| __________________ |
PONTIC HIGH NOBLE METAL
| 60.00 |
| EA |
| __________________ |
| __________________ |
PONTIC NOBLE METAL CAST
| 40.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN HIGH NOBLE
| 140.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN NOBLE METAL
| 115.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN/CERAMIC
| 100.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCELAIN/CERAMIC
| 70.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCLN HIGH NOBLE
| 15.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCLN NOBLE METAL
| 20.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN FULL HIGH NOBLE
| 20.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN FULL NOBLE METAL
| 460.00 |
| EA |
| __________________ |
| __________________ |
FIXED PROSTHODONTIC PROC
| 30.00 |
| EA |
| __________________ |
| __________________ |
FABRICATION ATHLETIC GUARD
| 35.00 |
| EA |
| __________________ |
| __________________ |
ADJUST OCCLUSAL GUARD
| 300.00 |
| EA |
| __________________ |
| __________________ |
OCCLUSAL GUARD HARD
| 45.00 |
| EA |
| __________________ |
| __________________ |
OCCLUSAL GUARD SOFT
| 180.00 |
| EA |
| __________________ |
| __________________ |
CUSTOM SLEEP APNEA APPLIANCE
| 25.00 |
| EA |
| __________________ |
| __________________ |
ADJ CUSTOM SLEEP APNEA APPL
OPTION YEAR 1 TOTAL
| 500.00 |
| EA |
| __________________ |
| __________________ |
CROWN PORCELAIN/CERAMIC SUBS
| 100.00 |
| EA |
| __________________ |
| __________________ |
CROWN PORCELAIN W/ H NOBLE M
| 100.00 |
| EA |
| __________________ |
| __________________ |
CROWN FULL CAST HIGH NOBLE M
| 35.00 |
| EA |
| __________________ |
| __________________ |
CROWN FULL CAST NOBLE METAL
| 80.00 |
| EA |
| __________________ |
| __________________ |
POST AND CORE CAST + CROWN
| 50.00 |
| EA |
| __________________ |
| __________________ |
PREFAB POST/CORE + CROWN
| 135.00 |
| EA |
| __________________ |
| __________________ |
UNSPECIFIED PERIODONTAL PROC
| 170.00 |
| EA |
| __________________ |
| __________________ |
DENTURES COMPLETE MAXILLARY
| 75.00 |
| EA |
| __________________ |
| __________________ |
DENTURES COMPLETE MANDIBLE
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENTURES IMMEDIAT MAXILLARY
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES IMMEDIAT MANDIBLE
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAXILL PART RESIN
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAND PART RESIN
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAXILL PART METAL
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MANDIBL PART METAL
| 25.00 |
| EA |
| __________________ |
| __________________ |
DENT IMMED MAXILL PART RESIN
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENT IMMED MAND PART RESIN
| 50.00 |
| EA |
| __________________ |
| __________________ |
MAXILLARY PART DENTURE FLEX
| 50.00 |
| EA |
| __________________ |
| __________________ |
MANDIBULAR PART DENTURE FLEX
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST CMPLT MAXIL
| 80.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST CMPLT MAND
| 110.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST PART MAXILL
| 125.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST PART MANDBL
| 60.00 |
| EA |
| __________________ |
| __________________ |
REPAIR DENTUR BASE CMPL MAND
| 80.00 |
| EA |
| __________________ |
| __________________ |
REPAIR DENTUR BASE CMPL MAX
| 100.00 |
| EA |
| __________________ |
| __________________ |
REPLACE DENTURE TEETH COMPLT
| 30.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL BASE MAND
| 35.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL BASE MAX
| 5.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL FRAMEW MAND
| 65.00 |
| EA |
| __________________ |
| __________________ |
REP PARTIAL DENTURE CLASP
| 100.00 |
| EA |
| __________________ |
| __________________ |
REPLACE PART DENTURE TEETH
| 100.00 |
| EA |
| __________________ |
| __________________ |
ADD TOOTH TO PARTIAL DENTURE
| 30.00 |
| EA |
| __________________ |
| __________________ |
ADD CLASP TO PARTIAL DENTURE
| 5.00 |
| EA |
| __________________ |
| __________________ |
DENTURES REBASE CMPLT MAXIL
| 5.00 |
| EA |
| __________________ |
| __________________ |
DENTURES REBASE CMPLT MAND
| 35.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAXIL CH
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAND CHR
| 55.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAXIL CHR
| 60.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAND CHR
| 55.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAX LAB
| 30.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAXIL LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
PART CMPLT SOFT RELN LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM CMPLT MAXILL
| 75.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM CMPLT MANDBL
| 60.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM PART MAXILL
| 120.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM PART MANDBL
| 130.00 |
| EA |
| __________________ |
| __________________ |
DENTURE TISS CONDITN MAXILL
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURE TISS CONDTIN MANDBL
| 5.00 |
| EA |
| __________________ |
| __________________ |
PRECISION ATTACHMENT REMOV
| 10.00 |
| EA |
| __________________ |
| __________________ |
OVERDENTURE PARTIAL MAX
| 15.00 |
| EA |
| __________________ |
| __________________ |
OVERDENTURE COMPLETE MAND
| 120.00 |
| EA |
| __________________ |
| __________________ |
REPLACEMENT OF PRECISION ATT
| 40.00 |
| EA |
| __________________ |
| __________________ |
PROSTHESIS MODIFICATION
| 300.00 |
| EA |
| __________________ |
| __________________ |
CUSTOM ABUTMENT
| 150.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN PORC/CER
| 15.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN PORC HNOB
| 30.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN ALL HNOB
| 20.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN ALL NOBL
| 115.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN PORC/CER
| 10.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN PORC MTL
| 15.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN ALL MTL
| 10.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT RETAIN PORC/CER
| 15.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT RETAIN PORC/CER
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT RETAIN PORC MTL
| 50.00 |
| EA |
| __________________ |
| __________________ |
GUIDED TISS REGEN RESORBLE
| 25.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV DENT MAX
| 25.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV DENT MAN
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV PRTL MAX
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV PRTL MAN
| 100.00 |
| EA |
| __________________ |
| __________________ |
RADIO/SURGICAL IMPLANT INDEX
| 100.00 |
| EA |
| __________________ |
| __________________ |
SEMIPRECISION ABUT
| 200.00 |
| EA |
| __________________ |
| __________________ |
SEMIPRECISION ATTACHMENT
| 15.00 |
| EA |
| __________________ |
| __________________ |
PONTIC HIGH NOBLE METAL
| 60.00 |
| EA |
| __________________ |
| __________________ |
PONTIC NOBLE METAL CAST
| 40.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN HIGH NOBLE
| 140.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN NOBLE METAL
| 115.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN/CERAMIC
| 100.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCELAIN/CERAMIC
| 70.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCLN HIGH NOBLE
| 15.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCLN NOBLE METAL
| 20.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN FULL HIGH NOBLE
| 20.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN FULL NOBLE METAL
| 460.00 |
| EA |
| __________________ |
| __________________ |
FIXED PROSTHODONTIC PROC
| 30.00 |
| EA |
| __________________ |
| __________________ |
FABRICATION ATHLETIC GUARD
| 35.00 |
| EA |
| __________________ |
| __________________ |
ADJUST OCCLUSAL GUARD
| 300.00 |
| EA |
| __________________ |
| __________________ |
OCCLUSAL GUARD HARD
| 45.00 |
| EA |
| __________________ |
| __________________ |
OCCLUSAL GUARD SOFT
| 180.00 |
| EA |
| __________________ |
| __________________ |
CUSTOM SLEEP APNEA APPLIANCE
| 25.00 |
| EA |
| __________________ |
| __________________ |
ADJ CUSTOM SLEEP APNEA APPL
OPTION YEAR 2 TOTAL
| 500.00 |
| EA |
| __________________ |
| __________________ |
CROWN PORCELAIN/CERAMIC SUBS
| 100.00 |
| EA |
| __________________ |
| __________________ |
CROWN PORCELAIN W/ H NOBLE M
| 100.00 |
| EA |
| __________________ |
| __________________ |
CROWN FULL CAST HIGH NOBLE M
| 35.00 |
| EA |
| __________________ |
| __________________ |
CROWN FULL CAST NOBLE METAL
| 80.00 |
| EA |
| __________________ |
| __________________ |
POST AND CORE CAST + CROWN
| 50.00 |
| EA |
| __________________ |
| __________________ |
PREFAB POST/CORE + CROWN
| 135.00 |
| EA |
| __________________ |
| __________________ |
UNSPECIFIED PERIODONTAL PROC
| 170.00 |
| EA |
| __________________ |
| __________________ |
DENTURES COMPLETE MAXILLARY
| 75.00 |
| EA |
| __________________ |
| __________________ |
DENTURES COMPLETE MANDIBLE
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENTURES IMMEDIAT MAXILLARY
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES IMMEDIAT MANDIBLE
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAXILL PART RESIN
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAND PART RESIN
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAXILL PART METAL
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MANDIBL PART METAL
| 25.00 |
| EA |
| __________________ |
| __________________ |
DENT IMMED MAXILL PART RESIN
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENT IMMED MAND PART RESIN
| 50.00 |
| EA |
| __________________ |
| __________________ |
MAXILLARY PART DENTURE FLEX
| 50.00 |
| EA |
| __________________ |
| __________________ |
MANDIBULAR PART DENTURE FLEX
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST CMPLT MAXIL
| 80.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST CMPLT MAND
| 110.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST PART MAXILL
| 125.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST PART MANDBL
| 60.00 |
| EA |
| __________________ |
| __________________ |
REPAIR DENTUR BASE CMPL MAND
| 80.00 |
| EA |
| __________________ |
| __________________ |
REPAIR DENTUR BASE CMPL MAX
| 100.00 |
| EA |
| __________________ |
| __________________ |
REPLACE DENTURE TEETH COMPLT
| 30.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL BASE MAND
| 35.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL BASE MAX
| 5.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL FRAMEW MAND
| 65.00 |
| EA |
| __________________ |
| __________________ |
REP PARTIAL DENTURE CLASP
| 100.00 |
| EA |
| __________________ |
| __________________ |
REPLACE PART DENTURE TEETH
| 100.00 |
| EA |
| __________________ |
| __________________ |
ADD TOOTH TO PARTIAL DENTURE
| 30.00 |
| EA |
| __________________ |
| __________________ |
ADD CLASP TO PARTIAL DENTURE
| 5.00 |
| EA |
| __________________ |
| __________________ |
DENTURES REBASE CMPLT MAXIL
| 5.00 |
| EA |
| __________________ |
| __________________ |
DENTURES REBASE CMPLT MAND
| 35.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAXIL CH
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAND CHR
| 55.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAXIL CHR
| 60.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAND CHR
| 55.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAX LAB
| 30.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAXIL LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
PART CMPLT SOFT RELN LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM CMPLT MAXILL
| 75.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM CMPLT MANDBL
| 60.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM PART MAXILL
| 120.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM PART MANDBL
| 130.00 |
| EA |
| __________________ |
| __________________ |
DENTURE TISS CONDITN MAXILL
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURE TISS CONDTIN MANDBL
| 5.00 |
| EA |
| __________________ |
| __________________ |
PRECISION ATTACHMENT REMOV
| 10.00 |
| EA |
| __________________ |
| __________________ |
OVERDENTURE PARTIAL MAX
| 15.00 |
| EA |
| __________________ |
| __________________ |
OVERDENTURE COMPLETE MAND
| 120.00 |
| EA |
| __________________ |
| __________________ |
REPLACEMENT OF PRECISION ATT
| 40.00 |
| EA |
| __________________ |
| __________________ |
PROSTHESIS MODIFICATION
| 300.00 |
| EA |
| __________________ |
| __________________ |
CUSTOM ABUTMENT
| 150.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN PORC/CER
| 15.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN PORC HNOB
| 30.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN ALL HNOB
| 20.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN ALL NOBL
| 115.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN PORC/CER
| 10.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN PORC MTL
| 15.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN ALL MTL
| 10.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT RETAIN PORC/CER
| 15.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT RETAIN PORC/CER
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT RETAIN PORC MTL
| 50.00 |
| EA |
| __________________ |
| __________________ |
GUIDED TISS REGEN RESORBLE
| 25.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV DENT MAX
| 25.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV DENT MAN
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV PRTL MAX
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV PRTL MAN
| 100.00 |
| EA |
| __________________ |
| __________________ |
RADIO/SURGICAL IMPLANT INDEX
| 100.00 |
| EA |
| __________________ |
| __________________ |
SEMIPRECISION ABUT
| 200.00 |
| EA |
| __________________ |
| __________________ |
SEMIPRECISION ATTACHMENT
| 15.00 |
| EA |
| __________________ |
| __________________ |
PONTIC HIGH NOBLE METAL
| 60.00 |
| EA |
| __________________ |
| __________________ |
PONTIC NOBLE METAL CAST
| 40.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN HIGH NOBLE
| 140.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN NOBLE METAL
| 115.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN/CERAMIC
| 100.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCELAIN/CERAMIC
| 70.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCLN HIGH NOBLE
| 15.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCLN NOBLE METAL
| 20.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN FULL HIGH NOBLE
| 20.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN FULL NOBLE METAL
| 460.00 |
| EA |
| __________________ |
| __________________ |
FIXED PROSTHODONTIC PROC
| 30.00 |
| EA |
| __________________ |
| __________________ |
FABRICATION ATHLETIC GUARD
| 35.00 |
| EA |
| __________________ |
| __________________ |
ADJUST OCCLUSAL GUARD
| 300.00 |
| EA |
| __________________ |
| __________________ |
OCCLUSAL GUARD HARD
| 45.00 |
| EA |
| __________________ |
| __________________ |
OCCLUSAL GUARD SOFT
| 180.00 |
| EA |
| __________________ |
| __________________ |
CUSTOM SLEEP APNEA APPLIANCE
| 25.00 |
| EA |
| __________________ |
| __________________ |
ADJ CUSTOM SLEEP APNEA APPL
OPTION YEAR 3 TOTAL
| 500.00 |
| EA |
| __________________ |
| __________________ |
CROWN PORCELAIN/CERAMIC SUBS
| 100.00 |
| EA |
| __________________ |
| __________________ |
CROWN PORCELAIN W/ H NOBLE M
| 100.00 |
| EA |
| __________________ |
| __________________ |
CROWN FULL CAST HIGH NOBLE M
| 35.00 |
| EA |
| __________________ |
| __________________ |
CROWN FULL CAST NOBLE METAL
| 80.00 |
| EA |
| __________________ |
| __________________ |
POST AND CORE CAST + CROWN
| 50.00 |
| EA |
| __________________ |
| __________________ |
PREFAB POST/CORE + CROWN
| 135.00 |
| EA |
| __________________ |
| __________________ |
UNSPECIFIED PERIODONTAL PROC
| 170.00 |
| EA |
| __________________ |
| __________________ |
DENTURES COMPLETE MAXILLARY
| 75.00 |
| EA |
| __________________ |
| __________________ |
DENTURES COMPLETE MANDIBLE
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENTURES IMMEDIAT MAXILLARY
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES IMMEDIAT MANDIBLE
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAXILL PART RESIN
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAND PART RESIN
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MAXILL PART METAL
| 50.00 |
| EA |
| __________________ |
| __________________ |
DENTURES MANDIBL PART METAL
| 25.00 |
| EA |
| __________________ |
| __________________ |
DENT IMMED MAXILL PART RESIN
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENT IMMED MAND PART RESIN
| 50.00 |
| EA |
| __________________ |
| __________________ |
MAXILLARY PART DENTURE FLEX
| 50.00 |
| EA |
| __________________ |
| __________________ |
MANDIBULAR PART DENTURE FLEX
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST CMPLT MAXIL
| 80.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST CMPLT MAND
| 110.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST PART MAXILL
| 125.00 |
| EA |
| __________________ |
| __________________ |
DENTURES ADJUST PART MANDBL
| 60.00 |
| EA |
| __________________ |
| __________________ |
REPAIR DENTUR BASE CMPL MAND
| 80.00 |
| EA |
| __________________ |
| __________________ |
REPAIR DENTUR BASE CMPL MAX
| 100.00 |
| EA |
| __________________ |
| __________________ |
REPLACE DENTURE TEETH COMPLT
| 30.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL BASE MAND
| 35.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL BASE MAX
| 5.00 |
| EA |
| __________________ |
| __________________ |
REPAIR PARTIAL FRAMEW MAND
| 65.00 |
| EA |
| __________________ |
| __________________ |
REP PARTIAL DENTURE CLASP
| 100.00 |
| EA |
| __________________ |
| __________________ |
REPLACE PART DENTURE TEETH
| 100.00 |
| EA |
| __________________ |
| __________________ |
ADD TOOTH TO PARTIAL DENTURE
| 30.00 |
| EA |
| __________________ |
| __________________ |
ADD CLASP TO PARTIAL DENTURE
| 5.00 |
| EA |
| __________________ |
| __________________ |
DENTURES REBASE CMPLT MAXIL
| 5.00 |
| EA |
| __________________ |
| __________________ |
DENTURES REBASE CMPLT MAND
| 35.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAXIL CH
| 20.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAND CHR
| 55.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAXIL CHR
| 60.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAND CHR
| 55.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAX LAB
| 30.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN CMPLT MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAXIL LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE RELN PART MAND LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
PART CMPLT SOFT RELN LAB
| 10.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM CMPLT MAXILL
| 75.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM CMPLT MANDBL
| 60.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM PART MAXILL
| 120.00 |
| EA |
| __________________ |
| __________________ |
DENTURE INTERM PART MANDBL
| 130.00 |
| EA |
| __________________ |
| __________________ |
DENTURE TISS CONDITN MAXILL
| 70.00 |
| EA |
| __________________ |
| __________________ |
DENTURE TISS CONDTIN MANDBL
| 5.00 |
| EA |
| __________________ |
| __________________ |
PRECISION ATTACHMENT REMOV
| 10.00 |
| EA |
| __________________ |
| __________________ |
OVERDENTURE PARTIAL MAX
| 15.00 |
| EA |
| __________________ |
| __________________ |
OVERDENTURE COMPLETE MAND
| 120.00 |
| EA |
| __________________ |
| __________________ |
REPLACEMENT OF PRECISION ATT
| 40.00 |
| EA |
| __________________ |
| __________________ |
PROSTHESIS MODIFICATION
| 300.00 |
| EA |
| __________________ |
| __________________ |
CUSTOM ABUTMENT
| 150.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN PORC/CER
| 15.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN PORC HNOB
| 30.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN ALL HNOB
| 20.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT CROWN ALL NOBL
| 115.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN PORC/CER
| 10.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN PORC MTL
| 15.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT CROWN ALL MTL
| 10.00 |
| EA |
| __________________ |
| __________________ |
ABUT SUPPORT RETAIN PORC/CER
| 15.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT RETAIN PORC/CER
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL SUPPORT RETAIN PORC MTL
| 50.00 |
| EA |
| __________________ |
| __________________ |
GUIDED TISS REGEN RESORBLE
| 25.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV DENT MAX
| 25.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV DENT MAN
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV PRTL MAX
| 5.00 |
| EA |
| __________________ |
| __________________ |
IMPL/ABUT SUPT REMV PRTL MAN
| 100.00 |
| EA |
| __________________ |
| __________________ |
RADIO/SURGICAL IMPLANT INDEX
| 100.00 |
| EA |
| __________________ |
| __________________ |
SEMIPRECISION ABUT
| 200.00 |
| EA |
| __________________ |
| __________________ |
SEMIPRECISION ATTACHMENT
| 15.00 |
| EA |
| __________________ |
| __________________ |
PONTIC HIGH NOBLE METAL
| 60.00 |
| EA |
| __________________ |
| __________________ |
PONTIC NOBLE METAL CAST
| 40.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN HIGH NOBLE
| 140.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN NOBLE METAL
| 115.00 |
| EA |
| __________________ |
| __________________ |
PONTIC PORCELAIN/CERAMIC
| 100.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCELAIN/CERAMIC
| 70.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCLN HIGH NOBLE
| 15.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN PORCLN NOBLE METAL
| 20.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN FULL HIGH NOBLE
| 20.00 |
| EA |
| __________________ |
| __________________ |
RET CROWN FULL NOBLE METAL
| 460.00 |
| EA |
| __________________ |
| __________________ |
FIXED PROSTHODONTIC PROC
| 30.00 |
| EA |
| __________________ |
| __________________ |
FABRICATION ATHLETIC GUARD
| 35.00 |
| EA |
| __________________ |
| __________________ |
ADJUST OCCLUSAL GUARD
| 300.00 |
| EA |
| __________________ |
| __________________ |
OCCLUSAL GUARD HARD
| 45.00 |
| EA |
| __________________ |
| __________________ |
OCCLUSAL GUARD SOFT
| 180.00 |
| EA |
| __________________ |
| __________________ |
CUSTOM SLEEP APNEA APPLIANCE
| 25.00 |
| EA |
| __________________ |
| __________________ |
ADJ CUSTOM SLEEP APNEA APPL
OPTION YEAR 4 TOTAL
| GRAND TOTAL |
| ______________ |
File details come from the government source that posted it. Updated .