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DIAGNOSTIC
Initial Oral
Evaluation
.........
Periodic Oral Evaluation
.
Limited Oral Evaluation - Problem Focused (Emergency)
...
X-Rays Intraoral - Complete Series (Incl. Bitewings)
..
X-Rays Intraoral - Periapical - First Film
..
X-Rays Intraoral - Periapical - Each Additional Film
X-Rays - Bitewing - Single Film
X-Ray Panoramic Film
. |
$19
$9
$17
$39
$9
$7
$7
$34
|
PREVENTIVE
Prophylaxis
(Cleaning)
..
Topical Application of Fluoride
Sealant - Per Tooth
..
Space Maintainer - Fixed - Unilateral Plus Lab
Space Maintainer - Fixed - Bilateral Plus Lab
.
Full Mouth Debridement
... |
$29
$18
$18
$110
$150
$65
|
RESTORATIVE
Amalgam - 1 Surface, Permanent
Amalgam - 2 Surfaces, Permanent
..
Amalgam - 3 Surfaces, Permanent
..
Amalgam - 4 or more Surfaces, Permanent
.
Resin - 1 Surface, Anterior
..
Resin - 2 Surfaces, Anterior
Resin - 3 Surfaces, Anterior
Resin - 1 Surface - Posterior Permanent
..
Resin - 2 Surfaces - Posterior Permanent
Resin - 3 (+)Surfaces - Posterior Permanent
|
$35
$45
$65
$80
$52
$75
$82
$68
$98
$115
|
CROWNS
Crown - Porcelain Fused to High Noble Metal
..
Crown - Porcelain Fused to Predominantly Base Metal
Crown - Full Cast Predominantly Base Metal
Prefabricated Stainless Steel Crown - Primary Tooth
Core Buildup, Including Any Pins
.
Pin Retention Per Tooth in Addition to Restoration
..
Cast Post and Core in Addition to Crown
..
|
$495
$460
$415
$125
$95
$24
$190 |
ENDODONTICS
Pulp Cap - Indirect Excluding Final Restoration
..
Therapeutic Pulpotomy Excluding Final Restoration
..
Root Canal Anterior Excluding Final Restoration
Root Canal Bicuspid Excluding Final Restoration
Root Canal Molar Excluding Final Restoration
|
$26
$55
$279
$345
$459 |
*Any procedure not listed is available on a fee for service
basis at a 25% discount from the participating provider's fee
schedule
All of the above charges are reduced fees for services
performed by a participating general dentist. Fees subject
to change without notice. Consult with your participating dentist
prior to beginning any treatment. Fees may not include all 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). Payments are subject to change without notification.
EDP Plan
1300 VETERANS MEMORIAL HIGHWAY
HAUPPAUGE NY 11788
631 272-5230
|
|
PROSTHDONTICS - REMOVABLE
Complete Denture Maxillary
........
Complete Denture Mandibular
....
Maxillary Partial Denture - Resin Base
.....
Mandibular Partial Denture - Resin Base
.......
Adjust Complete Denture - Maxillary (After 6 Mos.)..
Adjust Complete Denture - Mandibular (After 6 Mos)..
Repair Broken Complete Denture Base + Lab
Replace Missing/Broken Teeth - Complete Denture
..
Repair or Replace Broken Clasp
Add Tooth to Existing Partial Denture + Lab
.
Add Clasp to Existing Partial Denture + Lab
.
|
$575
$575
$460
$460
$34
$34
$80
$59
$69
$65
$80
|
FIXED PROSTHETICS
Pontic - Porcelain Fused to Predominantly Bast Metal..
Pontic - Porcelain Fused to Noble Metal
Crown - Procelain Fused to Predominantly Base Metal.
Crown - Porcelain Fused to Noble Metal
|
$440
$455
$450
$495
|
ORAL SURGERY
Extraction - Single Tooth
.
Extraction - Each Additional Tooth
.
Surgical Extraction - Removal of Impacted Tooth - Soft Tissue.
Surgical Extraction - Surgical Removal of Residual Roots
Incision & Drainage of Abscess - Intraoral Soft Tissue
|
$55
$52
$98
$105
$69
|
ORTHODONTICS
Comprehensive Orthodontic Treatment-Adolescent Dentition..
Comprehensive Orthodontic Treatment-Adult Dentition
|
25% off
25% off
|
PERIODONTICS
Gingivectomy or Gingivoplasty -
Per Quad
Peridontal Scaling & Root Planning - Per Quadrant
Peridontal Maintenance Proc. (Following Active Therapy)
|
$295
$115
$60
|
*Any
treatment provided by a participating specialist, if available, in Oral
Surgery, Orthodontics, Periodontics, Pedodontics or Endodontics will be
charged at a 25% reduction of participating specialist's fees for that
particular case.
Some
specialists may require a consultation visit before treatment is
initiated. Discuss each case with specialist prior to beginning any
treatment.
(1)
Work in progress is not covered. (2) Work in progress after enrollment on
the dental plan must be completed before selecting another participating
dentist. (3) Any dental procedures performed by a non-participating
dentist are not covered. (4) We cannot guarantee the continued
participation of any dentist. If he/she leaves the plan, you will need to
select another dentist. (5) 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. (6) Some providers may charge for missed or
broken appointments with no prior notice. (7) Please verify that the
dentist is a participating provider when scheduling your appointment.
Thank you for choosing
EDP
Plan.
We look forward to making you
smile...
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