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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
 
Services
bulletAppointments
bulletDiagnostics
bulletX-Rays
bulletPreventive
bulletSpace Maintainers
bulletRestorative
bulletCrowns and Bridges
bulletEndodontics
bulletPeriodontics
bulletProsthodontics
bulletRepairs to Prosthetics
bulletExtractions
bulletAnesthesia
bulletAdjunctive General Service
bulletOrthodontics
 

 

Extractions Service Rates
 
ADA
Code
Procedure Member
Pays
7110   Single tooth   No Charge
7120   Each additional tooth (per visit)   5.00
7210   Surgical extraction of erupted tooth   20.00
7220   Soft tissue impaction   25.00
7230   Partially bony impaction   50.00
7240   Completely bony impaction   75.00
7250   Surgical removal of residual tooth roots   20.00
7310   Alveoloplasty in conjunction with extractions (min 2 teeth)   25.00
7320   Alveoloplasty not in conjunction with extractions (per quadrant)   25.00
7510   Incision and drainage of abscess (intraoral)   18.00
7450   Surgical excision of cyst (up to 1.25 cm)   25.00
7451   Surgical excision of cyst (greater than 1.25 cm)   40.00
7960   Frenulectomy - frenectomy or frenotomy (separate procedures)   36.00
7970   Excision of hyperplastic tissue   35.00
 
 
Note
  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%.
     
 
Specialists
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%.
 

 

 

Current Dental Terminology © 2004 American Dental Association. All rights reserved

 

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