 |
Monthly |
| 1 Family Member- | $ 8.80 |
| 2 Family Members | $17.47 |
| 3 Family Members | $22.08 |
| 4 Family Members | $27.46 |
| 5 Family Members | $33.72 |
 -- -- -- |
Normal Dentist Fees * | Your Cost with ADP Coverage | You Save |
| Office Visit | $---- 8.00 | $-- 5.00 | $- 3.00 |
| Initial Oral Exam | $---20.00 | $-- 0.00 | $ 20.00 |
| Periodic Oral Exam | $---35.00 | $-- 0.00 | $ 35.00 |
| X-Ray, Bitewing-2 Films | $---40.00 | $-- 0.00 | $ 40.00 |
| X-Ray, Panoramic | $---60.00 | $-- 0.00 | $ 60.00 |
| Teeth Cleaning (Twice a Year) | $---70.00 | $-- 0.00 | $ 70.00 |
| Fluoride Application | $---15.00 | $-- 0.00 | $ 15.00 |
| Extraction--Single Tooth | $---65.00 | $ 20.00 | $ 45.00 |
| Fillings, Amalgan-1 Surface | $---30.00 | $ 20.00 | $ 10.00 |
| Root Canal, Molar | $--375.00 | $275.00 | $100.00 |
| Crown | $--450.00 | $305.00 | $145.00 |
| Totals | $1,168.00 | $625.00 | $543.00 |
SELECT 25 FLORIDA | Procedure | Patient Pays: |
| 9430 Office Visit (Normal Hours) | $ 5.00 |
| 9430 Emergency Visit (Regular Hours) | $20.00 |
| 9440 Emergency Visit (After Hours) | $35.00 |
| 0999 Broken Appointments (Without 24 Hours Notice, per 15 min) Maximum $40 per Broken Appointment No Charge will be made due to Emergencies | $10.00 |
| Procedure | Patient Pays: |
| 0140/0150/0160 Oral Evaluation | NO CHARGE |
| 0120 Periodic Oral Evaluation | NO CHARGE |
| 0470 Diagnostic Casts (Study Models) | NO CHARGE |
| 0999 Diagnosis and Treatment Plan Presentation | NO CHARGE |
| 9310 Consultation (second opinion) as Provided by Partcipating Dentists | $20.00 |
| 0460 Pulp Vitality Tests | NO CHARGE |
| Procedure | Patient Pays: | 0210 Intraoral - Complete Series | NO CHARGE |
| 0220 Intraoral - Periapical - First Film | NO CHARGE |
| 0230 Intraoral - Periapical - Each Additional Film | NO CHARGE |
| 0270 Bitewings - Single Film | NO CHARGE |
| 0272 Bitewings - Two Films | NO CHARGE |
| 0274 Bitewings - Four Films | NO CHARGE |
| 0330 Panoramic | NO CHARGE |
| Procedure | Patient Pays: |
| 1110/1120 Prophylaxis (routine, once every 6 months) | NO CHARGE |
| 1110/1120 Additional Prophylaxis | $24.00 |
| 1201/1203 Topical Application of Fluoride -(up to 16 years of age) | NO CHARGE |
| 1351 Sealant - per Tooth | $14.00 |
| 1330 Oral Hygiene Instruction | NO CHARGE |
| Procedure | Patient Pays: |
| 1510 Fixed, Unilateral | $60.00* |
| 1515 Fixed, Bilateral | $60.00* |
| 1520 Removable, Unilateral | $95.00- |
| 1525 Removable, Bilateral | $95.00* |
| 1550 Recementation of Space Maintainer | $12.00- |
| Procedure | Patient Pays: |
| 2999 Sedative Base (under fillings) | NO CHARGE |
| 2110/2140 One Surface Amalgam (Silver) | $ 20.00 |
| 2120/2150 Two Surfaces Amalgam (Silver) | $ 25.00 |
| 2130/2160 Three Surfaces Amalgam (Silver) | $ 35.00 |
| 2131/2161 Four or More Surfaces Amalgam (Silver) | $ 45.00 |
| 2330 Anterior One Surface Resin Restoration (including acid etch, glass ionomer liner) | $ 45.00 |
| 2331 Anterior Two Surfaces Resin Restoration (including acid etch, glass ionomer liner) | $ 50.00 |
| 2332 Anterior Three Surfaces Resin Restoration (including acid etch, glass ionomer liner) | $ 57.00 |
| 2510 Inlay - Metallic - One Surface | $ 90.00 |
| 2520 Inlay - Metallic - Two Surfaces | $120.00 |
| 2530 Inlay - Metallic - Three or More Surfaces | $150.00 |
| 2940 Sedative Filling | $ 15.00 |
| Procedure | Patient Pays: |
| 2930 Prefabricated Stainless Steel - Primary Tooth | $ 55.00 |
| 2790/2791/2792/6790/6791/6792 Full Cast Crown | $295.00 |
| 2750/2751/2752/6750/6751/6752 Porcelain Fused to Metal Crown | $305.00 |
| 2810 Three-quarter Cast Crown | $295.00 |
| 6210/6211/6212 Full Cast Pontic | $295.00 |
| 6240/6241/6242 Porcelain Fused to Metal Pontic | $305.00 |
| 2950 Core Build Up | $ 50.00 |
| 2951 Pin Retention - Per Tooth | $ 15.00 |
| 2952 Cast Post and Core | $ 95.00 |
| 2954 Prefabricated Post and Core | $ 85.00 |
| 2910/2920/6930 Recement Inlay/Onlay/Crown/Bridge (per unit) | $ 15.00 |
| Procedure | Patient Pays: |
| 3220 Therapeutic Pulpotomy | $ 35.00 | Root Canals | - |
| 3310 Anterior | $140.00 |
| 3320 Bicuspid | $225.00 |
| 3330 Molar | $275.00 |
| 3410 Apicoectomy (anterior only) | $140.00 |
| Procedure | Patient Pays: |
| 4210 Gingivectomy/Gingivoplasty - per Quadrant | $140.00 |
| 4211 Gingivectomy/Gingivoplasty - per Tooth | $ 43.00 |
| 4220 Gingival Curenaget Surgical - per Quadrant | $ 85.00 |
| 4341 Periodontal Scaling and Root Planing - per Quadrant | $ 60.00 |
| 4355 Full Mouth Debridement | $ 40.00 |
| 4381 Localized Delivery of Chemotherapeutic Agents (2 teeth) | $ 60.00 |
| 4910 Periodontal Maintenance Procedures | $ 50.00 |
| Procedure | Patient Pays: |
| Standard Complete Dentures (includes adjustments within 30 days) | - |
| 5110 Complete Maxillary (upper) | $325.00 |
| 5120 Complete Mandibular (lower) | $325.00 |
| 5130 Immediate Maxillary (upper) | $345.00 |
| 5140 Immediate Mandibular (lower) | $345.00 |
| Parbal Dentures (includes adjustments within 30 days) | - |
| 5211/5212 Maxillary/Mandibular Partial--Resinbase (with 2 clasps) | $320.00 |
| 5213/5214 Maxillary/Mandibular Partial -- Cast Metal with Resin Base (with 2 clasps) | $450.00 |
| 5410/5411 Adjust Complete - Maxillary/Mandibular | $ 15.00 |
| 5421/5422 Adjust Partial Denture - Maxillary/Mandibular | $ 15.00 |
| 5999 Additional Clasps | $ 35.00 |
| Procedure | Patient Pays: |
| 5510/5610 Repair Broken Resin Denture Base | $30.00- |
| 5520/5640 Replace Missing or Broken Teeth (each tooth) | $20.00* |
| 5520/5640 Each Additional Tooth | $15.00* |
| 5630 Repair or Replace Broken Clasp | $30.00* |
| 5650 Add Tooth to Existing Partial Denture | $30.00* |
| 5850/5851 Tissue Conditioning, Maxillary/Mandibular | $30.00- |
| 5730/5731/5740/5741 Relining (chairside) | $55.00- |
| 5750/5751/5760/5761 Relining (laboratory) | $45.00* |
| Procedure | Patient Pays: |
| 7110 Single Tooth | $ 20.00 |
| 7120 Each Additional Tooth (per visit) | $ 20.00 |
| 7130 Root Removal - Exposed Roots | $ 25.00 |
| 7210 Surgical Extraction of Erupted Tooth | $ 45.00 |
| 7220 Soft Tissue Impaction | $ 70.00 |
| 7230 Partially Bony Impaction | $ 85.00 |
| 7240 Completely Bony Impaction | $135.00 |
| 7250 Surgical Removal of Residual Tooth Roots | $ 45.00 |
| 7310 Alveoloplasty in Conjunction with Extractions - per Quadrant | $40.00 |
| 7320 Alveoloplasty not in Conjunction with Extractions - per Quadrant | $70.00 |
| Procedure | Patient Pays: |
| 9215 Local Anesthesia | NO CHARGE |
| 9230 Analgesia (nitrous oxide - per 15 minutes) | $15.00 |
| Procedure | Patient Pays: |
| 9951 Occlusal Adjustment - Limited | $ 35.00 |
| 9952 Occlusal Adjustment - Complete | $165.00 |
NOTE:- When crown and/or bridgework exceeds six consecutive units,
--------- the patient may be charged an additional $25.00 per unit.
* Plus laboratory fees when applicable.