36C26222Q1723.pdf

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. UEI: EFT:

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 ATTACHED

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. SIGNATURE 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. NOV 2021)

PREVIOUS EDITION IS NOT USABLE Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

36C26222Q1723 09-12-2022

Shavon Bogan 562-766-2216 09-26-2022

12:00PM PDT

36C262

Department of Veterans Affairs

Network Contracting Office 22

4811 Airport Plaza Drive

Suite 600

Long Beach CA 90815

X 100

X

339116

500 Employees

N/A

36C262

Department of Veterans Affairs

Network Contracting Office 22

4811 Airport Plaza Drive

Department of Veterans Affairs

Network Contracting Office 22

4811 Airport Plaza Drive

Financial Services Center www.tungsten-network.com/login

877-489-6135

See CONTINUATION Page

Dental Laboratory Services for the VA San Diego Healthcare

System.

This solicitation is set aside 100% for small businesses.

See subsequent pages for details.

See CONTINUATION Page

X 1

Shavon Bogan

36C26222Q1723

Table of Contents

SECTION A

A.1 SF 1449 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS

AND COMMERCIAL SERVICES

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

B.2 PERFORMANCE WORK STATEMENT

B.3 PRICE SCHEDULE

SECTION C - CONTRACT CLAUSES

C.1 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL PRODUCTS

AND COMMERCIAL SERVICES (NOV 2021)

C.2 52.216-18 ORDERING (AUG 2020)

C.3 52.216-19 ORDER LIMITATIONS (OCT 1995)

C.4 52.216-21 REQUIREMENTS (OCT 1995)

C.5 52.216-22 INDEFINITE QUANTITY (OCT 1995)

C.6 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999)

C.7 52.217-9 OPTION TO EXTEND THE TERM OF THE CONTRACT (MAR 2000) ...40

C.8 52.232-19 AVAILABILITY OF FUNDS FOR THE NEXT FISCAL YEAR (APR

1984)

C.9 VAAR 852.212-70 PROVISIONS AND CLAUSES APPLICABLE TO VA

ACQUISITION OF COMMERCIAL ITEMS (APR 2020)

C.10 VAAR 852.242-71 ADMINISTRATIVE CONTRACTING OFFICER (OCT 2020) ..42

C.11 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

C.12 52.212-5 CONTRACT TERMS AND CONDITIONS REQUIRED TO IMPLEMENT

STATUTES OR EXECUTIVE ORDERS—COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES (MAY 2022) (JUL 2020) (DEVIATION)

SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS

SECTION E - SOLICITATION PROVISIONS

E.1 52.212-1 INSTRUCTIONS TO OFFERORS—COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES (NOV 2021)

E.2 NOTIFICATION TO OFFERORS & PROPOSAL SUBMISSION INSTRUCTIONS ..56

E.3 52.212-2 EVALUATION—COMMERCIAL PRODUCTS AND COMMERCIAL

SERVICES (NOV 2021)

E.4 52.204-24 REPRESENTATION REGARDING CERTAIN TELECOMMUNICATIONS

AND VIDEO SURVEILLANCE SERVICES OR EQUIPMENT (NOV 2021)

E.5 52.209-7 INFORMATION REGARDING RESPONSIBILITY MATTERS (OCT 2018)

E.6 52.216-1 TYPE OF CONTRACT (APR 1984)

E.7 52.233-2 SERVICE OF PROTEST (SEP 2006)

E.8 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB

1998)

E.9 52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS—

COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES (MAY 2022) (JUL 2020)

(DEVIATION)

SECTION B - CONTINUATION OF SF 1449 BLOCKS

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 36C262 Shavon Bogan

Network Contracting Office 22

4811 Airport Plaza Drive

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

[X] 52.232-36, Payment by Third Party

3. INVOICES: Invoices shall be submitted in arrears:

a. Quarterly []

b. Semi-Annually []

c. Other [X] Net 30

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.

ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

AMENDMENT NO DATE

B.2 PERFORMANCE WORK STATEMENT

1. Background. The VA San Diego Healthcare System (VASDHS) located at 3350 La Jolla

Village Dr. San Diego, CA 92161; VA San Diego Community Based Outpatient Clinic at

Oceanside located at 1300 Rancho Del Oro Dr. Oceanside, CA 92056; and the VA San

Diego Community Based Outpatient Clinic at Kearny Mesa located at 8875 Aero Dr. San

Diego, CA 92130 currently serves over an estimated 100,000 Veterans. The VASDHS

Dental Department provides a multitude of dental services for Veteran Beneficiaries which includes providing various dental implants, bridges, crowns, etc. that require fabrication at a dental laboratory facility.

2. General Requirement. The Contractor shall provide all labor, facilities, transportation, and management necessary to provide fixed and removable dental fabrications, including assisted/implant supported dental prosthesis, for Veteran Beneficiaries. The Contractor’s facility shall be a full-service dental laboratory that can integrate the combined treatment needs of the prosthetic patient requiring simultaneous fixed, removable, and implant supported/assisted prostheses. The Contractor is required to attend Veteran appointments at the VASDHS when needed, often on short notice based on urgency to provide dental supplies and or assistance with dental prosthesis.

3. Contractor Facility Location. The Contractor shall have a full-service laboratory within a sixty (60) mile radius of the VASDHS with the ability to provide facility request for prosthesis adjustments with same day pick-up and next day delivery for urgent orders.

4. Pick-Up and Delivery. The Contractor shall pick-up or arrange to have delivered to their place of business, prescriptions/specifications, and impressions between the hours of

8:00am and 3:00pm PST Monday – Friday excluding national holidays at no additional cost to the Government. Orders placed by the Government prior to 12:00pm PST shall be picked up the same day, while orders placed after 12:00pm PST shall be picked up no later than the following business day. Dental fabrications produced under this contract shall be delivered to the VASDHS and all pick-ups and deliveries must be made in person directly to the Dental Service Department. The Contractor shall deliver all completed orders no later than fourteen (14) calendar days from the date the order is placed, or some other agreed upon date by both the Contractor and the requesting Dental

Service Department for non-urgent orders.

5. Products and Services. The Contractor shall fabricate the following items in the manner specified below:

a. All metal crown and bridges shall be cast in noble or high noble metal as indicated by the Dentist.

b. Porcelain fused to metal crowns/bridges shall be cast in high noble white metal.

Occlusal/lingual surfaces may be porcelain/metal, or full metal design per the prescription. Esthetic margins may be metal, porcelain/metal, or porcelain per the prescription.

c. Full or partial coverage ceramic restorations with options as required per the prescription (ex. Empress, procera, captek, zirconia, etc.)

d. Intracoronal ceramic restorations with options as required per the prescription.

e. Cast removable partial denture frameworks shall be casted in Vitallium metal, unless otherwise prescribed, and may include necessary wroght wire clasp or modification spaces.

f. Resin retained bridges shall be cast in non-noble metal and include one or two retainers of any design and one pontic of any design.

g. Full or partial dentures may be returned for try-in or taken to finish as per the prescription. Denture teeth shall be provided when requested by the Dentist. All dentures shall be processed using Lucitone 199 or equivalent materials unless otherwise prescribed and include patient identification processed in denture.

All Contractor supplied dental prosthesis supplied to the VASDHS Dental Department shall comply with all applicable regulations and standards of the Food and Drug

Administration (FDA) found at www.fda.gov, American National Standards Institute

(ANSI) www.ansi.org, and the American Dental Association www.ada.org. The

Contractor shall fabricate all dental prosthesis or appliances assembled or created under the contract in the United States. The Contractor shall provide descriptions of metal alloy components and percentages of each used in the fabrication of each of the requested dental prosthesis.

6. Repairs and Remakes. The Contractor shall repair, modify, adjust, and remake new original restorations/prosthesis at no charge to the Government if there has been no requested change from the original prescription (Rx) or preparation or if the restorations do not fit original models. There shall also be no charge to the Government if dentist changes the shade, but corrections can be made without remaking the restoration or stripping porcelain. The following are examples of no charge repairs:

a. Add contacts

b. Polish or re-size

c. Shade correction (to comply with original prescription)

d. Add porcelain

e. Re-contour

f. Add to pontic area

Contractor shall not charge the Government additional shipping or transportation fees associated with returning or replacing restorations/prosthesis requiring repair, modification, adjustment, or remake if the Contractor did not mee the conditions of the prescription, or if the restoration/prosthesis do not fit the original models.

http://www.fda.gov/ http://www.ansi.org/ http://www.ada.org/

7. Warranties. The following warranties shall be provided by the Contractor as identified below:

a. Remakes and Repairs. All remakes and repairs that fall within the warranty periods specified below for the items specified below, shall be remade by the

Contractor at no charge to the Government if the material has not changed. The original restorations/prosthesis must be picked up by the Contractor and returned to the Contractor’s lab for remake cases.

b. Warranty Conditions. Notwithstanding any other warranty provisions found in the terms of this contract, the Contractor shall provide the warranties specified below, for the items specified, for any defects discovered in original restorations/prosthesis during the applicable warranty period specified below.

Any damage to original restorations/prosthesis due to trauma or normal wear and tea is excluded from these warranties. Additional restorative procedures may void warranty. All warranties shall be remedied by remake of original class of restorations/prosthesis at no charge to the Government. The Contractor shall bear all shipping and transportation cost associated with original restorations/prosthesis requiring warranty services.

c. One-Year Conditional Warranty Items. The Contractor shall provide a one-year warranty, subject to the conditions specified in paragraph 8.b above for the following items.

i. Porcelain Veneers (Including all Nano Veneer Restorations)

ii. IPS empress Veneers, Crowns, Onlay, or Inlays

iii. Nano Veneers, Ultra and Simply Thin

iv. Empress Esthetic

v. Feldspathic Porcelain Onlay/Inlay

vi. Composite bridges

vii. Maryland bridges

d. Five-Year Conditional Warranty Items. The Contractor shall provide a five-following items:

i. Procera

ii. Lava

iii. Captek

iv. Zirconia

v. eMax (Lithium Disilicate) Layered

vi. eMax Monolithic (Lithium Disilicate)

vii. Porcelain fused to metal

viii. Zir-MAX L Layered Zirconia

ix. BruxZir

x. Composites (Sculpture, Belle-SDss NG, Diamond Crown, and Cristobal) excluding mutually opposing implant-supported full bridges and Maryland and inlay/onlay bridges

xi. Full metal crowns

e. Six-Month Conditional Warranty Items (Removable Prosthesis). The

Contractor shall provide a six-month warranty, subject to the conditions specified in paragraph 8.b above for the following items:

i. Night guards

ii. Acrylic splints

iii. Talon splints

iv. Sleep apnea appliances (EMA, Silencer, TAP’3, and Herbst)

v. Sports guards

vi. Acrylic partial

vii. DuraTemps

f. One-Year Conditional Warranty Items (Removable Prosthesis). The

Contractor shall provide a one-year warranty, subject to the conditions specified in paragraph 8.b above for the following items:

i. Full dentures

ii. Vitallium cast frames and partials

iii. Flexible thermoplastic (Valplast) partials

g. Thirty-Day Conditional Warranty Items: The Contractor shall provide a one-following items:

i. Immediate dentures

ii. Immediate flexible nylon partials

iii. Acrylic flippers

iv. Retainers

v. Surgical and radiographic guides and all other dental devices if the failures are due to defects in materials or workmanship

8. Quality /Workmanship. The VASDHS Dentist shall at their sole discretion determine of the quality of the fabrication of the restoration/prosthesis is acceptable. The VHA dental staff shall inspect each of the prosthesis including fit, finish, esthetics, patient comfort and satisfaction prior to final acceptance of any restoration/prosthesis. The Contractor shall deliver all items returned for subsequent adjustments and/or reworks to the

VASDHS dental office no later than seven (7) calendar days after the re-order is placed at no additional cost to the Government. The Contractor shall use the following quality checklists during the fabrication of restorations/prosthesis:

a. Fixed Prosthesis Quality Checklist:

i. Restoration matches Rx

ii. Shade matches Rx

iii. Restoration fits model

iv. Marginal adaptation is accurate

v. Marginal ridges harmonize with teeth

vi. Proximal contacts are correct

vii. Occlusion meets doctor’s Rx

viii. Tooth anatomy is correct

ix. Restoration harmonizes with teeth

x. Restoration is polished and cleaned

b. Removable Prosthesis Quality Checklist:

i. Restoration matches Rx

ii. Restoration fits model

iii. Occlusion is correct

iv. Esthetics is correct

v. Restoration harmonizes with remaining teeth

vi. Restoration is polished and cleaned

vii. Shade matches Rx

viii. Periphery is correct

ix. Appropriate acrylic base thickness (~2mm), clasp, retainers, proximal plates, rests should have proper dimension, thickness, and must follow the design

9. Ordering. The Contracting Officer (CO) and the Contracting Officer Representative

(COR) are the only individuals authorized to place orders against this contract. CORs may place verbal orders against the established task orders obligated with annual appropriations.

10. Packaging. The Contractor shall adhere to the following guidelines when packaging products for delivery to the VASDHS:

a. Remove dies from models, wrap in cotton, and place in plastic containers

b. Wrap all components individually in bubble wrap and secured.

c. Pack items securely in a shipping box with sufficient bubble wrap to avoid movement during shipment/transport.

d. All completed cases shall be disinfected and returned to the VASDHS via shipping methods defined by the clinic.

e. The Contractor must identify the specific type of metal used in each prosthesis with the shipment.

11. Qualification of Key Personnel and Facilities. All Dental Lab Technicians that the

Contractor uses to perform work under this contract shall have successfully passed a written and practical exam from an accredited institution and possess the practical knowledge necessary to ensure the accuracy of all orders to the prescriptions and provide accurate and detailed information regarding lab cases.

12. Patient Confidentiality. The Contractor shall ensure the confidentiality of all patient information and shall be liable for any breach of confidentiality. Contractor shall be provided with the patient’s name. That information shall not be disclosed. The

Contractor shall follow all Health Insurance Portability and Accountability Act (HIPAA) guidance.

The Contractor shall take reasonable measures to ensure patient privacy and confidentiality. Additionally, the Contractor shall take all reasonable precautions to safeguard patient information from unauthorized access or modification, in both electronic and hard-copy formats.

The Contractor shall ensure the proper transfer of patient information via electronic means, such as faxing or system to system transmission. The Contractor shall ensure that no patient information of any type shall be given to outside parties, agencies, or organizations of any type without the expressed written consent of the patient and the

VASDHS and only in capacities directly related to the provision of the services provided under this contract. The Contractor shall ensure that only the minimum necessary patient information is used to provide appropriate service to the correct patient.

13. Hours of Service. The Contractor shall pick-up from the VASDHS Dental Service

Department or arrange to have delivered to their place of business prescription/specifications and impressions between the hours of 8:00am and 3:00pm

PST Monday – Friday, excluding national holidays.

14. National Holidays

New Year’s Day 1 January

Martin Luther King’s Birthday Third Monday in January

President’s Day Third Monday in February

Memorial Day Last Monday in May

Juneteenth 19 June

Independence Day 4 July

Labor Day First Monday in September

Columbus Day Second Monday in October

Veterans Day 11 November

Thanksgiving Day 4th Thursday in November

Christmas Day 25 December

If a holiday falls on Sunday, the following Monday shall be observed as the National

Holiday. When a holiday falls on a Saturday, the preceding Friday is observed as a

National Holiday by U.S. Government agencies. Also included would be any day specifically declared by the President of the United States of America as a National

Holiday.

15. Badges. All Contractor personnel shall wear identification (ID) badges during the entire time they are on the VA grounds. I.D. badges must have identification picture, name of the individual and the represented company depicted on it.

16. Parking. It is the responsibility of Contractor personnel to park only in designated parking areas. Parking information is available from the VA Security Service. The VA shall not invalidate or make reimbursement for parking violations of the Contractor's personnel under any circumstances.

17. Smoking Policy. Smoking is not permitted within or around the VA Healthcare System facilities.

18. Additional Services. The Contractor is advised that only the Contracting Officer, acting within the scope of the contract has the authority to make changes which affect the contract in terms of quality, quantity, price, or delivery. Only those services specified within this contract are authorized. In the event the Contractor initiates any such change at the direction of any person other than the Contracting Officer, the change shall be considered to have been made without authority and no adjustment shall be made in the contract price to cover any costs incurred as a result thereof.

19. VA Policies. Possession of weapons is prohibited on VA property. Enclosed containers, including tool kits, are subject to search. Violations of VA regulations may result in citations answerable in the United States (Federal) District Court.

20. Billing Procedures. The Contractor shall coordinate with Tungsten Network System for arrangement of direct deposit payment. The Contractor shall submit a monthly invoice in the arrears to the VA COR and through the Tungsten Network System at the end of each month for payment of work completed in that billing period. The invoice shall indicate the purchase order number, obligation number, and itemized list of services provided to include patient name and amount separated by ordering individual. In addition, an individual invoice should accompany each delivered final product.

B.3 PRICE SCHEDULE

This is an indefinite delivery, indefinite quantity (IDIQ); firm-fixed price contract. Prices in this schedule represent an all-inclusive rate including labor, incidental cost, overhead, and insurance premium payments for applicable insurance coverage. Cost not incorporated into the contractor’s price will not be reimbursed by the Government.

The guaranteed minimum amount for this contract is $2,000.00. The maximum aggregate value of the orders that can be placed under this contract is $4,273,852.00The Government does not guarantee that it will place any orders under this contract in excess of the guaranteed minimum amount. Unit prices below are applicable to each of the participating facilities identified in section B.2.

The previous option period pricing will apply to any extensions pursuant to FAR 52.217-8

The contract period of performance for this IDIQ is a base period of one (1) year, and four (4) one-year option periods to be exercised at the discretion of the Government.

Base Year: October 1, 2022 – September 30, 2023

CLIN ITEM DESCRIPTION

Unit of

Measure

Unit

Price

Metal Ceramic Restorations

0001 PFM -high noble alloy [1] EA

0002 PFM- Nonprecious alloy [1] EA

0003 Single anterior PFM (#6 - 11) (esthetic case- high noble alloy [1]) EA

0004 Additional labor cost for splinted PFM per unit) EA

0005 Pontic/Bridge PFM- high noble alloy [1] EA

0006 Pontic/Bridge PFM non-precious alloy [1] EA

0007 PFM Press- On-Metal technique (posteriors only) EA

0008 CAPTEK crown EA

0009 Maryland Bridge -high noble alloy [1] EA

0010 Maryland bridge Additional Pontic -high noble alloy [1] EA

0011 Additional Wing Extension Maryland bridge EA

0012 Rest on crown EA

0013 Guide Plane EA

Labor for attachment on crowns. Additional charge for attachment/component cost [2]

EA

0015 Solder EA

0016 Post-Solder EA

0017 Laser welding EA

0018 Porcelain margin labor EA

0019 Pink porcelain per crown unit EA

0020 Metal occlusal suface for crown (labor only) EA

All Ceramic Restoration- Zirconia

0021 Zirconia crown EA

0022 Anterior zirconia crown (single crown #6-11) EA

0023 Layered zirconia crown EA

0024 Zirconia bridge/Pontic EA

0025 IPS Empress crown EA

0026 IPS empress inlay/onlay EA

0027 Lava crown EA

0028 Feldspathic porcelain veneer EA

0029 Feldspathic porcelain inlay/onlay EA

0030 e.max Crown EA

0031 e.max inlay/onlay EA

0032 e.max veneer EA

All Metal Restorations

0033 Full Metal Crown -high noble alloy [1] EA

0034 Full Metal Crown-nonprecious alloy [1] EA

0035 Metal inlay/onlay -high noble alloy [1] EA

0036 Metal inlay/onlay non-precious alloy [1] EA

0037 Pontic high noble metal [1] EA

0038 Cast post and dowel core [1] EA

Implant restorations

0039 Implant Cement Retained PFM- high noble alloy [1] EA

0040 Implant Cement Retained PFM- non-precious alloy [1] EA

0041 Anterior Implant Cement Retained PFM- high noble alloy [1] EA

Screw Retained implant PFM [1]- high noble alloy [1] (Additional charge for implant components [2])

EA

Screw Retained anterior implant PFM - high noble alloy [1]

(Additional charge for implant components [2])

EA

0044 Screw Retained implant high noble metal crown [1] EA

0045 (Additional charge for implant components [2]) EA

0046 Additional labor cost for splinted implant PFM per unit EA

0047 Zirconia cement retained implant crown EA

0048 Zirconia screw retained implant crown EA

0049 e.max crown cement retained implant crown EA

Implant hybrid prosthesis (case complete include metal bar 3-6 implants, process, denture teeth)

0051 CAD/CAM milled titanium bar for implants (3-6 implants) EA

Cast implant metal bar labor only. (Additional charge for alloy [1] and components [2])

EA

Implant abutments

0053 Titanium/Zirconia abutment preparation (labor only) EA

0054 Titanium abutment, CAD/CAM milled EA

0055 Gold hue titanium abutment (CAD/CAM milled) EA

Cast custom abutment/UCLA abutment - (Additional charge for alloy

[1] and components [2])

EA

0057 Zirconia abutment, CAD/CAM milled EA

0058 Zirconia on titanium base abutment EA

Implant stents/index

0058 Surgical stent EA

0059 Surgical stent with CT markers EA

0060 Abutment placement guide/stent/index EA

Other services

0061 Shade Take/Custom shade EA

0062 Provisional/Temporary crown per unit EA

0063 Provisional/Temporary crown with fiber/wire reinforcement per unit EA

0064 Provisional/Temporary implant crown per unit EA

0065 Diagnostic Wax Up per unit EA

0066 Pour stone model EA

0067 Pindex model EA

0068 Pour stone model with soft tissue EA

0069 Bleaching tray EA

0070 Custom tray EA

Removable Lab Procedures (3)

0071 Acrylic Partial Plus Teeth and Clasps 1-3 teeth EA

0072 Acrylic Partial Plus Teeth and Clasps 4-6 teeth EA

0073 Acrylic Partial Plus Teeth and Clasps 7-14 teeth EA

0074 Flex partial denture (Valplast) includes teeth EA

0075 Flex partial denture (Valplast) with metal framework EA

Vitalium partial denture plus teeth (start to finish including custom tray, record base, set up teeth, process and finish)

EA

0077 Vitalium partial denture framework only EA

Full denture (Luciton 199, from start to finish including custom tray, record base, set up teeth, process and finish)

EA

0079 Denture rebase EA

0080 Hard reline (lab hard reline) denture/partial EA

0081 Soft reline (lab soft reline) denture/partial EA

0082 Wire clasp/Ball clasp EA

0083 Mesh strengthener for removable prosthesis EA

Repair acrylic denture regular (Crack, add acrylic to small area, loose saddle, denture broken in less than 3 pieces)

0085 Repair denture extensive (cracks, dentures broken in 3 pieces or more) EA

0086 Valplast /flex denture repair EA

Add or replace denture teeth per tooth (including the cost of denture teeth)

EA

0088 Add or replace wire clasp EA

0089 Solder wrough wire clasp to metal framework EA

Process attachment (Hader clip, locator, ERA) in denture (Additional charge for components/attachment) [2]

EA

0091 Name/ID in full or partial denture EA

0092 Custom tray EA

0093 Record base and wax rim/bite block EA

0094 Set up teeth for try-in (labor only) EA

0095 Reset teeth to new bite for try-in EA

0096 Process and finish denture only (heat process) EA

0097 Remount jig EA

0098 Characterization denture EA

0099 Night guard/Occlusal guard (hard) EA

0100 Night guard/Occlusal guard (soft and hard) EA

0101 Night guard/ Occlusal guard (soft) EA

0102 Talon occlusal/night guard EA

0103 TMJ splint/Bruxism splint EA

Attachments (additional charge for attachment)

0104 Locator attachments [2] EA

0105 Era Attachment [2] EA

0106 Zest Anchor Attachment [2] EA

0107 Hader/Dolder Attachment [2] EA

Sleep Apnea Devices

0108 EMA sleep apnea device EA

0109 Silencer (MAD device for sleep apnea) EA

0110 TAP 3 (MAD device) EA

0111 Obturators EA

0112 Radiation Shield EA

0113 Nasal prosthesis EA

0114 Auricular (ear) prosthesis EA

0115 Orbital prosthesis EA

0116 Ocular prosthesis EA

0117 Facial prosthesis EA

0118 Feeding aid EA

0119 Palatal lift prosthesis EA

0120 Speech aid prosthesis EA

0121 Surgical stent EA

0122 Surgical splint EA

0123 Tongue depressor/bite opener EA

Option Year One: October 1, 2023 – September 30, 2024

CLIN ITEM DESCRIPTION

Unit of

Measure

Unit

Price

Metal Ceramic Restorations

0001 PFM -high noble alloy [1] EA

0002 PFM- Nonprecious alloy [1] EA

0003 Single anterior PFM (#6 - 11) (esthetic case- high noble alloy [1]) EA

0004 Additional labor cost for splinted PFM per unit) EA

0005 Pontic/Bridge PFM- high noble alloy [1] EA

0006 Pontic/Bridge PFM non-precious alloy [1] EA

0007 PFM Press- On-Metal technique (posteriors only) EA

0008 CAPTEK crown EA

0009 Maryland Bridge -high noble alloy [1] EA

0010 Maryland bridge Additional Pontic -high noble alloy [1] EA

0011 Additional Wing Extension Maryland bridge EA

0012 Rest on crown EA

0013 Guide Plane EA

Labor for attachment on crowns. Additional charge for attachment/component cost [2]

EA

0015 Solder EA

0016 Post-Solder EA

0017 Laser welding EA

0018 Porcelain margin labor EA

0019 Pink porcelain per crown unit EA

0020 Metal occlusal suface for crown (labor only) EA

All Ceramic Restoration- Zirconia

0021 Zirconia crown EA

0022 Anterior zirconia crown (single crown #6-11) EA

0023 Layered zirconia crown EA

0024 Zirconia bridge/Pontic EA

0025 IPS Empress crown EA

0026 IPS empress inlay/onlay EA

0027 Lava crown EA

0028 Feldspathic porcelain veneer EA

0029 Feldspathic porcelain inlay/onlay EA

0030 e.max Crown EA

0031 e.max inlay/onlay EA

0032 e.max veneer EA

All Metal Restorations

0033 Full Metal Crown -high noble alloy [1] EA

0034 Full Metal Crown-nonprecious alloy [1] EA

0035 Metal inlay/onlay -high noble alloy [1] EA

0036 Metal inlay/onlay non-precious alloy [1] EA

0037 Pontic high noble metal [1] EA

0038 Cast post and dowel core [1] EA

Implant restorations

0039 Implant Cement Retained PFM- high noble alloy [1] EA

0040 Implant Cement Retained PFM- non-precious alloy [1] EA

0041 Anterior Implant Cement Retained PFM- high noble alloy [1] EA

Screw Retained implant PFM [1]- high noble alloy [1] (Additional charge for implant components [2])

EA

Screw Retained anterior implant PFM - high noble alloy [1]

(Additional charge for implant components [2])

EA

0044 Screw Retained implant high noble metal crown [1] EA

0045 (Additional charge for implant components [2]) EA

0046 Additional labor cost for splinted implant PFM per unit EA

0047 Zirconia cement retained implant crown EA

0048 Zirconia screw retained implant crown EA

0049 e.max crown cement retained implant crown EA

Implant hybrid prosthesis (case complete include metal bar 3-6 implants, process, denture teeth)

EA

0051 CAD/CAM milled titanium bar for implants (3-6 implants) EA

Cast implant metal bar labor only. (Additional charge for alloy [1] and components [2])

EA

Implant abutments

0053 Titanium/Zirconia abutment preparation (labor only) EA

0054 Titanium abutment, CAD/CAM milled EA

0055 Gold hue titanium abutment (CAD/CAM milled) EA

Cast custom abutment/UCLA abutment - (Additional charge for alloy

[1] and components [2])

EA

0057 Zirconia abutment, CAD/CAM milled EA

0058 Zirconia on titanium base abutment EA

Implant stents/index

0058 Surgical stent EA

0059 Surgical stent with CT markers EA

0060 Abutment placement guide/stent/index EA

Other services

0061 Shade Take/Custom shade EA

0062 Provisional/Temporary crown per unit EA

0063 Provisional/Temporary crown with fiber/wire reinforcement per unit EA

0064 Provisional/Temporary implant crown per unit EA

0065 Diagnostic Wax Up per unit EA

0066 Pour stone model EA

0067 Pindex model EA

0068 Pour stone model with soft tissue EA

0069 Bleaching tray EA

0070 Custom tray EA

Removable Lab Procedures (3)

0071 Acrylic Partial Plus Teeth and Clasps 1-3 teeth EA

0072 Acrylic Partial Plus Teeth and Clasps 4-6 teeth EA

0073 Acrylic Partial Plus Teeth and Clasps 7-14 teeth EA

0074 Flex partial denture (Valplast) includes teeth EA

0075 Flex partial denture (Valplast) with metal framework EA

Vitalium partial denture plus teeth (start to finish including custom tray, record base, set up teeth, process and finish)

EA

0077 Vitalium partial denture framework only EA

Full denture (Luciton 199, from start to finish including custom tray, record base, set up teeth, process and finish)

EA

0079 Denture rebase EA

0080 Hard reline (lab hard reline) denture/partial EA

0081 Soft reline (lab soft reline) denture/partial EA

0082 Wire clasp/Ball clasp EA

0083 Mesh strengthener for removable prosthesis EA

Repair acrylic denture regular (Crack, add acrylic to small area, loose saddle, denture broken in less than 3 pieces)

EA

0085 Repair denture extensive (cracks, dentures broken in 3 pieces or more) EA

0086 Valplast /flex denture repair EA

Add or replace denture teeth per tooth (including the cost of denture teeth)

EA

0088 Add or replace wire clasp EA

0089 Solder wrough wire clasp to metal framework EA

Process attachment (Hader clip, locator, ERA) in denture (Additional charge for components/attachment) [2]

EA

0091 Name/ID in full or partial denture EA

0092 Custom tray EA

0093 Record base and wax rim/bite block EA

0094 Set up teeth for try-in (labor only) EA

0095 Reset teeth to new bite for try-in EA

0096 Process and finish denture only (heat process) EA

0097 Remount jig EA

0098 Characterization denture EA

0099 Night guard/Occlusal guard (hard) EA

0100 Night guard/Occlusal guard (soft and hard) EA

0101 Night guard/ Occlusal guard (soft) EA

0102 Talon occlusal/night guard EA

0103 TMJ splint/Bruxism splint EA

Attachments (additional charge for attachment)

0104 Locator attachments [2] EA

0105 Era Attachment [2] EA

0106 Zest Anchor Attachment [2] EA

0107 Hader/Dolder Attachment [2] EA

Sleep Apnea Devices

0108 EMA sleep apnea device EA

0109 Silencer (MAD device for sleep apnea) EA

0110 TAP 3 (MAD device) EA

0111 Obturators EA

0112 Radiation Shield EA

0113 Nasal prosthesis EA

0114 Auricular (ear) prosthesis EA

0115 Orbital prosthesis EA

0116 Ocular prosthesis EA

0117 Facial prosthesis EA

0118 Feeding aid EA

0119 Palatal lift prosthesis EA

0120 Speech aid prosthesis EA

0121 Surgical stent EA

Option Year Two: October 1, 2024 – September 30, 2025

CLIN ITEM DESCRIPTION

Unit of

Measure

Unit

Price

Metal Ceramic Restorations

0001 PFM -high noble alloy [1] EA

0002 PFM- Nonprecious alloy [1] EA

0003 Single anterior PFM (#6 - 11) (esthetic case- high noble alloy [1]) EA

0004 Additional labor cost for splinted PFM per unit) EA

0005 Pontic/Bridge PFM- high noble alloy [1] EA

0006 Pontic/Bridge PFM non-precious alloy [1] EA

0007 PFM Press- On-Metal technique (posteriors only) EA

0008 CAPTEK crown EA

0009 Maryland Bridge -high noble alloy [1] EA

0010 Maryland bridge Additional Pontic -high noble alloy [1] EA

0011 Additional Wing Extension Maryland bridge EA

0012 Rest on crown EA

0013 Guide Plane EA

Labor for attachment on crowns. Additional charge for attachment/component cost [2]

EA

0015 Solder EA

0016 Post-Solder EA

0017 Laser welding EA

0018 Porcelain margin labor EA

0019 Pink porcelain per crown unit EA

0020 Metal occlusal suface for crown (labor only) EA

All Ceramic Restoration- Zirconia

0021 Zirconia crown EA

0022 Anterior zirconia crown (single crown #6-11) EA

0023 Layered zirconia crown EA

0024 Zirconia bridge/Pontic EA

0025 IPS Empress crown EA

0026 IPS empress inlay/onlay EA

0027 Lava crown EA

0028 Feldspathic porcelain veneer EA

0029 Feldspathic porcelain inlay/onlay EA

0030 e.max Crown EA

0031 e.max inlay/onlay EA

0032 e.max veneer EA

All Metal Restorations

0035 Metal inlay/onlay -high noble alloy [1] EA

0036 Metal inlay/onlay non-precious alloy [1] EA

0037 Pontic high noble metal [1] EA

0038 Cast post and dowel core [1] EA

Implant restorations

0039 Implant Cement Retained PFM- high noble alloy [1] EA

0040 Implant Cement Retained PFM- non-precious alloy [1] EA

0041 Anterior Implant Cement Retained PFM- high noble alloy [1] EA

Screw Retained implant PFM [1]- high noble alloy [1] (Additional charge for implant components [2])

EA

Screw Retained anterior implant PFM - high noble alloy [1]

(Additional charge for implant components [2])

EA

0044 Screw Retained implant high noble metal crown [1] EA

0045 (Additional charge for implant components [2]) EA

0046 Additional labor cost for splinted implant PFM per unit EA

0047 Zirconia cement retained implant crown EA

0048 Zirconia screw retained implant crown EA

0049 e.max crown cement retained implant crown EA

Implant hybrid prosthesis (case complete include metal bar 3-6 implants, process, denture teeth)

EA

0051 CAD/CAM milled titanium bar for implants (3-6 implants) EA

Cast implant metal bar labor only. (Additional charge for alloy [1] and components [2])

EA

Implant abutments

0053 Titanium/Zirconia abutment preparation (labor only) EA

0054 Titanium abutment, CAD/CAM milled EA

0055 Gold hue titanium abutment (CAD/CAM milled) EA

Cast custom abutment/UCLA abutment - (Additional charge for alloy

[1] and components [2])

EA

0057 Zirconia abutment, CAD/CAM milled EA

0058 Zirconia on titanium base abutment EA

Implant stents/index

0058 Surgical stent EA

0059 Surgical stent with CT markers EA

0060 Abutment placement guide/stent/index EA

Other services

0061 Shade Take/Custom shade EA

0062 Provisional/Temporary crown per unit EA

0063 Provisional/Temporary crown with fiber/wire reinforcement per unit EA

0064 Provisional/Temporary implant crown per unit EA

0065 Diagnostic Wax Up per unit EA

0066 Pour stone model EA

0069 Bleaching tray EA

0070 Custom tray EA

Removable Lab Procedures (3)

0071 Acrylic Partial Plus Teeth and Clasps 1-3 teeth EA

0072 Acrylic Partial Plus Teeth and Clasps 4-6 teeth EA

0073 Acrylic Partial Plus Teeth and Clasps 7-14 teeth EA

0074 Flex partial denture (Valplast) includes teeth EA

0075 Flex partial denture (Valplast) with metal framework EA

Vitalium partial denture plus teeth (start to finish including custom tray, record base, set up teeth, process and finish)

EA

0077 Vitalium partial denture framework only EA

Full denture (Luciton 199, from start to finish including custom tray, record base, set up teeth, process and finish)

EA

0079 Denture rebase EA

0080 Hard reline (lab hard reline) denture/partial EA

0081 Soft reline (lab soft reline) denture/partial EA

0082 Wire clasp/Ball clasp EA

0083 Mesh strengthener for removable prosthesis EA

Repair acrylic denture regular (Crack, add acrylic to small area, loose saddle, denture broken in less than 3 pieces)

EA

0085 Repair denture extensive (cracks, dentures broken in 3 pieces or more) EA

0086 Valplast /flex denture repair EA

Add or replace denture teeth per tooth (including the cost of denture teeth)

EA

0088 Add or replace wire clasp EA

0089 Solder wrough wire clasp to metal framework EA

Process attachment (Hader clip, locator, ERA) in denture (Additional charge for components/attachment) [2]

EA

0091 Name/ID in full or partial denture EA

0092 Custom tray EA

0093 Record base and wax rim/bite block EA

0094 Set up teeth for try-in (labor only) EA

0095 Reset teeth to new bite for try-in EA

0096 Process and finish denture only (heat process) EA

0097 Remount jig EA

0098 Characterization denture EA

0099 Night guard/Occlusal guard (hard) EA

0100 Night guard/Occlusal guard (soft and hard) EA

0101 Night guard/ Occlusal guard (soft) EA

0102 Talon occlusal/night guard EA

0103 TMJ splint/Bruxism splint EA

0105 Era Attachment [2] EA

0106 Zest Anchor Attachment [2] EA

0107 Hader/Dolder Attachment [2] EA

Sleep Apnea Devices

0108 EMA sleep apnea device EA

0109 Silencer (MAD device for sleep apnea) EA

0110 TAP 3 (MAD device) EA

0111 Obturators EA

0112 Radiation Shield EA

0113 Nasal prosthesis EA

0114 Auricular (ear) prosthesis EA

0115 Orbital prosthesis EA

0116 Ocular prosthesis EA

0117 Facial prosthesis EA

0118 Feeding aid EA

0119 Palatal lift prosthesis EA

0120 Speech aid prosthesis EA

0121 Surgical stent EA

Option Year Three: October 1, 2025 – September 30, 2026

CLIN ITEM DESCRIPTION

Unit of

Measure

Unit

Price

Metal Ceramic Restorations

0001 PFM -high noble alloy [1] EA

0002 PFM- Nonprecious alloy [1] EA

0003 Single anterior PFM (#6 - 11) (esthetic case- high noble alloy [1]) EA

0004 Additional labor cost for splinted PFM per unit) EA

0005 Pontic/Bridge PFM- high noble alloy [1] EA

0006 Pontic/Bridge PFM non-precious alloy [1] EA

0007 PFM Press- On-Metal technique (posteriors only) EA

0008 CAPTEK crown EA

0009 Maryland Bridge -high noble alloy [1] EA

0010 Maryland bridge Additional Pontic -high noble alloy [1] EA

0011 Additional Wing Extension Maryland bridge EA

0012 Rest on crown EA

0013 Guide Plane EA

Labor for attachment on crowns. Additional charge for attachment/component cost [2]

EA

0015 Solder EA

0016 Post-Solder EA

0017 Laser welding EA

0018 Porcelain margin labor EA

0019 Pink porcelain per crown unit EA

0020 Metal occlusal suface for crown (labor only) EA

All Ceramic Restoration- Zirconia

0021 Zirconia crown EA

0022 Anterior zirconia crown (single crown #6-11) EA

0023 Layered zirconia crown EA

0024 Zirconia bridge/Pontic EA

0025 IPS Empress crown EA

0026 IPS empress inlay/onlay EA

0027 Lava crown EA

0028 Feldspathic porcelain veneer EA

0029 Feldspathic porcelain inlay/onlay EA

0030 e.max Crown EA

0031 e.max inlay/onlay EA

0032 e.max veneer EA

All Metal Restorations

0035 Metal inlay/onlay -high noble alloy [1] EA

0036 Metal inlay/onlay non-precious alloy [1] EA

0037 Pontic high noble metal [1] EA

0038 Cast post and dowel core [1] EA

Implant restorations

0039 Implant Cement Retained PFM- high noble alloy [1] EA

0040 Implant Cement Retained PFM- non-precious alloy [1] EA

0041 Anterior Implant Cement Retained PFM- high noble alloy [1] EA

Screw Retained implant PFM [1]- high noble alloy [1] (Additional charge for implant components [2])

EA

Screw Retained anterior implant PFM - high noble alloy [1]

(Additional charge for implant components [2])

EA

0044 Screw Retained implant high noble metal crown [1] EA

0045 (Additional charge for implant components [2]) EA

0046 Additional labor cost for splinted implant PFM per unit EA

0047 Zirconia cement retained implant crown EA

0048 Zirconia screw retained implant crown EA

0049 e.max crown cement retained implant crown EA

Implant hybrid prosthesis (case complete include metal bar 3-6 implants, process, denture teeth)

EA

0051 CAD/CAM milled titanium bar for implants (3-6 implants) EA

Cast implant metal bar labor only. (Additional charge for alloy [1] and components [2])

EA

Implant abutments

0053 Titanium/Zirconia abutment preparation (labor only) EA

0054 Titanium abutment, CAD/CAM milled EA

0055 Gold hue titanium abutment (CAD/CAM milled) EA

Cast custom abutment/UCLA abutment - (Additional charge for alloy

[1] and components [2])

EA

0057 Zirconia abutment, CAD/CAM milled EA

0058 Zirconia on titanium base abutment EA

Implant stents/index

0058 Surgical stent EA

0059 Surgical stent with CT markers EA

0060 Abutment placement guide/stent/index EA

Other services

0061 Shade Take/Custom shade EA

0062 Provisional/Temporary crown per unit EA

0063 Provisional/Temporary crown with fiber/wire reinforcement per unit EA

0064 Provisional/Temporary implant crown per unit EA

0065 Diagnostic Wax Up per unit EA

0066 Pour stone model EA

0069 Bleaching tray EA

0070 Custom tray EA

Removable Lab Procedures (3)

0071 Acrylic Partial Plus Teeth and Clasps 1-3 teeth EA

0072 Acrylic Partial Plus Teeth and Clasps 4-6 teeth EA

0073 Acrylic Partial Plus Teeth and Clasps 7-14 teeth EA

0074 Flex partial denture (Valplast) includes teeth EA

0075 Flex partial denture (Valplast) with metal framework EA

Vitalium partial denture plus teeth (start to finish including custom tray, record base, set up teeth, process and finish)

EA

0077 Vitalium partial denture framework only EA

Full denture (Luciton 199, from start to finish including custom tray, record base, set up teeth, process and finish)

EA

0079 Denture rebase EA

0080 Hard reline (lab hard reline) denture/partial EA

0081 Soft reline (lab soft reline) denture/partial EA

0082 Wire clasp/Ball clasp EA

0083 Mesh strengthener for removable prosthesis EA

Repair acrylic denture regular (Crack, add acrylic to small area, loose saddle, denture broken in less than 3 pieces)

EA

0085 Repair denture extensive (cracks, dentures broken in 3 pieces or more) EA

0086 Valplast /flex denture repair EA

Add or replace denture teeth per tooth (including the cost of denture teeth)

EA

0088 Add or replace wire clasp EA

0089 Solder wrough wire clasp to metal framework EA

Process attachment (Hader clip, locator, ERA) in denture (Additional charge for components/attachment) [2]

EA

0091 Name/ID in full or partial denture EA

0092 Custom tray EA

0093 Record base and wax rim/bite block EA

0094 Set up teeth for try-in (labor only) EA

0095 Reset teeth to new bite for try-in EA

0096 Process and finish denture only (heat process) EA

0097 Remount jig EA

0098 Characterization denture EA

0099 Night guard/Occlusal guard (hard) EA

0100 Night guard/Occlusal guard (soft and hard) EA

0101 Night guard/ Occlusal guard (soft) EA

0102 Talon occlusal/night guard EA

0103 TMJ splint/Bruxism splint EA

0105 Era Attachment [2] EA

0106 Zest Anchor Attachment [2] EA

0107 Hader/Dolder Attachment [2] EA

Sleep Apnea Devices

0108 EMA sleep apnea device EA

0109 Silencer (MAD device for sleep apnea) EA

0110 TAP 3 (MAD device) EA

0111 Obturators EA

0112 Radiation Shield EA

0113 Nasal prosthesis EA

0114 Auricular (ear) prosthesis EA

0115 Orbital prosthesis EA

0116 Ocular prosthesis EA

0117 Facial prosthesis EA

0118 Feeding aid EA

0119 Palatal lift prosthesis EA

0120 Speech aid prosthesis EA

0121 Surgical stent EA

Option Year Four: October 1, 2026 – September 30, 2027

CLIN ITEM DESCRIPTION

Unit of

Measure

Unit

Price

Metal Ceramic Restorations

0001 PFM -high noble alloy [1] EA

0002 PFM- Nonprecious alloy [1] EA

0003 Single anterior PFM (#6 - 11) (esthetic case- high noble alloy [1]) EA

0004 Additional labor cost for splinted PFM per unit) EA

0005 Pontic/Bridge PFM- high noble alloy [1] EA

0006 Pontic/Bridge PFM non-precious alloy [1] EA

0007 PFM Press- On-Metal technique (posteriors only) EA

0008 CAPTEK crown EA

0009 Maryland Bridge -high noble alloy [1] EA

0010 Maryland bridge Additional Pontic -high noble alloy [1] EA

0011 Additional Wing Extension Maryland bridge EA

0012 Rest on crown EA

0013 Guide Plane EA

Labor for attachment on crowns. Additional charge for attachment/component cost [2]

EA

0015 Solder EA

0016 Post-Solder EA

0017 Laser welding EA

0018 Porcelain margin labor EA

0019 Pink porcelain per crown unit EA

0020 Metal occlusal suface for crown (labor only) EA

All Ceramic Restoration- Zirconia

0021 Zirconia crown EA

0022 Anterior zirconia crown (single crown #6-11) EA

0023 Layered zirconia crown EA

0024 Zirconia bridge/Pontic EA

0025 IPS Empress crown EA

0026 IPS empress inlay/onlay EA

0027 Lava crown EA

0028 Feldspathic porcelain veneer EA

0029 Feldspathic porcelain inlay/onlay EA

0030 e.max Crown EA

0031 e.max inlay/onlay EA

0032 e.max veneer EA

All Metal Restorations

0035 Metal inlay/onlay -high noble alloy [1] EA

0036 Metal inlay/onlay non-precious alloy [1] EA

0037 Pontic high noble metal [1] EA

0038 Cast post and dowel core [1] EA

Implant restorations

0039 Implant Cement Retained PFM- high noble alloy [1] EA

0040 Implant Cement Retained PFM- non-precious alloy [1] EA

0041 Anterior Implant Cement Retained PFM- high noble alloy [1] EA

Screw Retained implant PFM [1]- high noble alloy [1] (Additional charge for implant components [2])

EA

Screw Retained anterior implant PFM - high noble alloy [1]

(Additional charge for implant components [2])

EA

0044 Screw Retained implant high noble metal crown [1] EA

0045 (Additional charge for implant components [2]) EA

0046 Additional labor cost for splinted implant PFM per unit EA

0047 Zirconia cement retained implant crown EA

0048 Zirconia screw retained implant crown EA

0049 e.max crown cement retained implant crown EA

Implant hybrid prosthesis (case complete include metal bar 3-6 implants, process, denture teeth)

EA

0051 CAD/CAM milled titanium bar for implants (3-6 implants) EA

Cast implant metal bar labor only. (Additional charge for alloy [1] and components [2])

EA

Implant abutments

0053 Titanium/Zirconia abutment preparation (labor only) EA

0054 Titanium abutment, CAD/CAM milled EA

0055 Gold hue titanium abutment (CAD/CAM milled) EA

Cast custom abutment/UCLA abutment - (Additional charge for alloy

[1] and components [2])

EA

0057 Zirconia abutment, CAD/CAM milled EA

0058 Zirconia on titanium base abutment EA

Implant stents/index

0058 Surgical stent EA

0059 Surgical stent with CT markers EA

0060 Abutment placement guide/stent/index EA

Other services

0061 Shade Take/Custom shade EA

0062 Provisional/Temporary crown per unit EA

0063 Provisional/Temporary crown with fiber/wire reinforcement per unit EA

0064 Provisional/Temporary implant crown per unit EA

0065 Diagnostic Wax Up per unit EA

0066 Pour stone model EA

0069 Bleaching tray EA

0070 Custom tray EA

Removable Lab Procedures (3)

0071 Acrylic Partial Plus Teeth and Clasps 1-3 teeth EA

0072 Acrylic Partial Plus Teeth and Clasps 4-6 teeth EA

0073 Acrylic Partial Plus Teeth and Clasps 7-14 teeth EA

0074 Flex partial denture (Valplast) includes teeth EA

0075 Flex partial denture (Valplast) with metal framework EA

Vitalium partial denture plus teeth (start to finish including custom tray, record base, set up teeth, process and finish)

EA

0077 Vitalium partial denture framework only EA

Full denture (Luciton 199, from start to finish including custom tray, record base, set up teeth, process and finish)

EA

0079 Denture rebase EA

0080 Hard reline (lab hard reline) denture/partial EA

0081 Soft reline (lab soft reline) denture/partial EA

0082 Wire clasp/Ball clasp EA

0083 Mesh strengthener for removable prosthesis EA

Repair acrylic denture regular (Crack, add acrylic to small area, loose saddle, denture broken in less than 3 pieces)

EA

0085 Repair denture extensive (cracks, dentures broken in 3 pieces or more) EA

0086 Valplast /flex denture repair EA

Add or replace denture teeth per tooth (including the cost of denture teeth)

EA

0088 Add or replace wire clasp EA

0089 Solder wrough wire clasp to metal framework EA

Process attachment (Hader clip, locator, ERA) in denture (Additional charge for components/attachment) [2]

EA

0091 Name/ID in full or partial denture EA

0092 Custom tray EA

0093 Record base and wax rim/bite block EA

0094 Set up teeth for try-in (labor…