ADP Standard Plan Schedule


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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

	Appointments
	Diagnostics
	X-Rays
	Preventive
	Space Maintainers
	Restorative
	Crowns and Bridges
	Endodontics

	Periodontics
	Prosthodontics
	Repairs to Prosthetics
	Extractions
	Oral Surgery
	Anesthesia
	Adjunctive General Service
	Orthodontics

Preventive Care Services



Procedure				Member Pays


Cleaning (semi-annual prophylaxis to include scaling & polishing)				No Charge

Additional cleanings				$15.00

Topical fluoride treatment				No Charge

Sealants (pit & tissue, per tooth)				7.00

Preventive dental education & instruction				No Charge

Exclusions and Limitations

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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