As an EDP Dental Plan member, you’ll always save up to 60% on quality dental care for virtually all the procedures you require. These are the prices members pay directly to the participating general dental office at time of services.
| ADA | Diagnostics | |
| 120 | Periodic Oral Evaluation | $20 |
| 140 | Limited Oral Evaluation – Problem Focused (Emergency) | $35 |
| 150 | Comprehensive Oral Evaluation | $25 |
| 210 | X-Rays Intraoral – Complete Series (Incl. Bitewings) | $59 |
| 220 | X-Rays Intraoral – Periapical – First Film | $12 |
| 230 | X-Rays Intraoral – Periapical – Each Additional Film | $8 |
| 240 | X-Rays – Intraoral – Occlusal Film | $19 |
| 270 | X-Rays – Bitewing – Single Film | $12 |
| 272 | X-Rays – Bitewing – Two Films | $18 |
| 274 | X-Rays – Bitewing – Four Films | $30 |
| 330 | X-Ray Panoramic Film | $58 |
| ADA | Preventative | |
| 1110 | Dental Prophylaxis Adult(Cleaning) | $48 |
| 1120 | Dental Prophylaxis Children | $38 |
| 1204 | Topical Fluoride Application | $20 |
| 1351 | Topical Sealants – Per Tooth | $27 |
| ADA | Restorative (fillings) | |
| 2140 | Amalgam – 1 Surface, Permanent | $58 |
| 2150 | Amalgam – 2 Surfaces, Permanent | $75 |
| 2160 | Amalgam – 3 Surfaces, Permanent | $88 |
| 2161 | Amalgam – 4 or more Surfaces, Permanent | $115 |
| 2330 | Resin – 1 Surface, Anterior | $75 |
| 2331 | Resin – 2 Surfaces, Anterior | $92 |
| 2332 | Resin – 3 Surfaces, Anterior | $115 |
| 2335 | Resin – 4+ Surf Or Inv. Incisal Angle | $145 |
| 2391 | Resin – 1 Surface – Posterior – Permanent | $98 |
| 2392 | Resin – 2 Surfaces – Posterior – Permanent | $135 |
| 2393 | Resin – 3 Surfaces – Posterior – Permanent | $155 |
| 2394 | Resin – 4+ Surfaces – Posterior – Permanent | $205 |
| ADA | Crowns (lab fees additional) | |
| 2740 | Crown – Porcelain/Ceramic Substrate | $698 |
| 2750 | Crown – Porcelain/High Noble Metal | $655 |
| 2751 | Crown – Porcelain/Predominate Base Metal | $625 |
| 2752 | Crown – Porcelain/Noble Metal | $638 |
| 2790 | Crown – Full Cast High Noble Metal | $645 |
| 2791 | Crown – Full Cast Predominantly Base Metal | $630 |
| 2920 | Re-cement Crown | $60 |
| 2930 | Prefabricated Stainless Steel Crown – Primary Tooth | $135 |
| 2931 | Prefabricated Stainless Steel Crown – Perm Tooth | $155 |
| 2932 | Prefab Resin Crown | $175 |
| 2950 | Core Buildup, Including Any Pins | $130 |
| 2951 | Pin Retention Per Tooth (W/O Restoration) | $32 |
| 2952 | Cast Post/Core (Addition to Crown) | $210 |
| 2954 | Prefabricated Post and Core (Addition to Crown) | $165 |
| 2970 | Temporary Crown (Fractured Tooth) | $155 |
| ADA | Endodontics (General Dentist) exc. Final Restoration | |
| 3220 | Therapeutic Pulpotomy | $78 |
| 3310 | Root Canal Anterior | $385 |
| 3320 | Root Canal Bicuspid | $465 |
| 3330 | Root Canal Molar | $585 |
| ADA | Prosthodontics (Performed by a General Dentist) | |
| 4210 | Gingivectomy/Gingivoplasty – 4+ contiguous teeth | $355 |
| 4341 | Perio. Scaling & Root Planning per Quad | $135 |
| 4355 | Full Mouth Debridement | $90 |
| 4910 | Periodontal Maintenance | $88 |
| ADA | Prosthodontics, Removable (lab fees additional) | |
| 5110 | Complete Upper Denture | $745 |
| 5120 | Complete Lower Denture | $745 |
| 5130 | Immediate Upper | $745 |
| 5140 | Immediate Lower | $825 |
| 5211 | Upper Partial-Resin Base | $775 |
| 5212 | Lower Partial-Resin Base | $775 |
| 5213 | Partial Upper Cast Metal Base | $795 |
| 5214 | Partial Lower Cast Metal Base | $795 |
| 5410 | Adjust Denture (Upper) | $42 |
| 5411 | Adjust Denture (Lower) | $42 |
| 5510 | Repair Broken Complete Denture Base | $105 |
| 5520 | Repair Missing or Broken Teeth/Each Tooth | $75 |
| 5610 | Repair Resin Denture Base | $95 |
| 5630 | Repair or Replace Broken Clasp | $85 |
| 5640 | Repair Broken Teeth – Per Tooth | $70 |
| 5650 | Add Tooth to Existing Partial Denture | $80 |
| 5660 | Add Clasp to Existing Partial Denture | $95 |
| 5730 | Reline Upper Denture – Chairside | $145 |
| 5731 | Reline Lower Denture – Chairside | $145 |
| ADA | Prosthodontics, Fixed (lab fees additional) | |
| 6240 | Pontic – Porcelain/High Noble Metal | $585 |
| 6241 | Pontic – Porcelain/Predominate Base Metal | $535 |
| 6242 | Pontic – Porcelain/Noble Metal | $545 |
| 6750 | Crown – Porcelain/High Noble Metal | $595 |
| 6751 | Crown – Procelain/Predominate Base Metal | $545 |
| 6752 | Crown – Porcelain/Noble Metal | $555 |
| 6930 | Re-cement Bridge | $75 |
| ADA | Oral Surgery | |
| 7140 | Single Tooth Extraction | $75 |
| 7120 | Each Additional Extraction | $65 |
| 7210 | Surgical Removal of Erupted Tooth | $170 |
| 7220 | Removal of Impacted Tooth/Soft Tissue | $160 |
| 7230 | Removal of Impacted Tooth/Partially BOny | $200 |
| 7240 | Removal of Impacted Tooth/Completely Bony | $255 |
| 7250 | Surgical Removal of Residual Tooth Roots | $138 |
| 7510 | Incision & Drainage of Abscess/Intraoral | $95 |
| ADA | Orthodontics | |
| 8080 | Comprehensive Treatment – Adolescent | 25% off |
| 8090 | Comprehensive Treatment – Adult | 25% off |
| ADA | Adjunctive Services | |
| 9110 | Palliative Treatment (emergency) Pain-minor | $50 |
| 9610 | Therapeutic Drug Injection | $45 |
*This Fee Schedule applies only to services performed by a participating EDP General Dentist, NOT SPECIALISTS.
*Any treatment provided by a participating specialist, (Oral Surgeon, Orthodontist, Periodontist, Pedodontist, Endodontist or Prosthodontist) will be charged at a 25% reduction of the participating specialist’s fees for that particular case.
Fee’s subject to change without notice. Consult with your participating dentist prior to beginning any treatment. Fees do not include lab costs, which would be the member’s responsibility. Some services, at the discretion of the general dentist, may need to be referred to a specialist (advanced degree).
Any procedure not listed is available on a fee for service basis at a 25% discount from the participating provider’s usual fee.
PLEASE NOTE:
EDP Dental Plan is a discount dental plan, NOT INSURANCE. EDP Dental Plan does not pay claims. Charges for services are paid by the member directly to the participating dentist at time of service.
- Work in progress is not covered.
- Work in progress after enrollment on the dental plan must be completed before selecting another participating dentist.
- Any dental procedures performed by a non-participating dentist are not covered.
- We cannot guarantee the continued participation of any dentist. If he/she leaves the plan, you will need to select another dentist.
- Not all types of dentists may be available in your area; you may have to travel to receive care from a participating general dentist or specialist.
- Some providers may charge for missed or broken appointments with no prior notice.
- Please verify that the dentist is a participating provider when scheduling your appointment.
