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ADP Enriched Plan Schedule of Benefits1

The co-payments listed below are the maximum fees that will be charged by the Participating General Dentist for the specified covered services.

1Select a service below
bulletSpace Maintainers
bulletCrowns and Bridges
bulletRepairs to Prosthetics
bulletAdjunctive General Service


Adjunctive General Service Rates
Procedure Member
9951   Occlusal adjustment - limited   20.00
9952   Occlusal adjustment - complete   150.00
  1. When crown and/or bridgework exceeds six consecutive units, the patient may be charged an additional $25.00 per unit.
  2. All procedures listed may not be performed by the Participating General Dentist you select. The co-payments shown apply to those American Dental Plan Participating Dentists who do perform those services. Therefore, you are encouraged to discuss availability of the scheduled services with your Participating General Dentist. Procedures not listed on the schedule of benefits, that are performed by the selected Participating General Dentist will be charged at that Participating General Dentist's usual and customary fee less 25%.
Should you need a specialist (i.e. Endodontist, Orthodontist, Oral Surgeon, Periodontist, Prosthodontist, Pediatric Dentist), you may be referred by your Participating General Dentist. Co-payment amounts are applicable when treatment is performed by selected Participating General Dentist or by Participating Specialists. Benefits for procedures not listed on the schedule of benefits, that are performed by a Participating Specialist, are available at the Participating Specialist's usual and customary fee less 25%.



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