| Note |
�
Per unit, up to six (6) units. Seven (7) or more units,
add an additional $40 per unit. Laboratory processed
temporary splint, add an additional $25 per unit for
seven (7) or more units.
|
| The co-payments listed are the maximum fees that will be charged by
the Participating General Dentist for the specified covered services. |
| |
| Should you need a specialist (i.e., Endodontist, Orthodontist, Oral Surgeon,
Periodontist, Prosthodontist, Pediatric Dentist), you may refer yourself
to any Participating Specialist from our directory, Upon identifying yourself
as an American Dental Plan member, you will receive a 25% reduction from
usual and customary fees for services performed. |
| |
| All procedures listed may not be performed by the Participating General Dentist. Therefore, you
are encouraged to discuss availability of the scheduled services with your
Participating General Dentist. |
| |
| Specialist services are available only in
areas where American Dental plan has a Participating Specialist. |
| |
