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ADP Standard 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
 
Services
bulletAppointments
bulletDiagnostics
bulletX-Rays
bulletPreventive
bulletSpace Maintainers
bulletRestorative
bulletCrowns and Bridges
bulletEndodontics
bulletPeriodontics
bulletProsthodontics
bulletRepairs to Prosthetics
bulletExtractions
bulletOral Surgery
bulletAnesthesia
bulletAdjunctive General Service
bulletOrthodontics
 
 
Exclusions and Limitations
The co-payments listed are the maximum fees that will be charged by the Participating General Dentist for the specified covered services.
 
All dental services and procedures performed by Participating Specialists are at usual fees less 25% were applicable.
 
*Surcharges apply only when treatment is performed at a participating dental office. If the services of a specialist are required, these surcharges do not apply.
 

 

 

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