General Dentist Fee Schedule

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) $50
220 X-Rays Intraoral – Periapical – First Film $10
230 X-Rays Intraoral – Periapical – Each Additional Film $7
240 X-Rays – Intraoral – Occlusal Film $19
270 X-Rays – Bitewing – Single Film $12
272 X-Rays – Bitewing – Two Films $15
274 X-Rays – Bitewing – Four Films $28
330 X-Ray Panoramic Film $52
ADA Preventative  
1110 Dental Prophylaxis Adult(Cleaning) $42
1120 Dental Prophylaxis Children $35
1208 Topical Fluoride Application $15
1351 Topical Sealants – Per Tooth $24
ADA Restorative (fillings)  
2140 Amalgam – 1 Surface, Permanent $52
2150 Amalgam – 2 Surfaces, Permanent $65
2160 Amalgam – 3 Surfaces, Permanent $80
2161 Amalgam – 4 or more Surfaces, Permanent $105
2330 Resin – 1 Surface, Anterior $65
2331 Resin – 2 Surfaces, Anterior $85
2332 Resin – 3 Surfaces, Anterior $105
2335 Resin – 4+ Surf Or Inv. Incisal Angle $130
2380 Resin – 1 Surface – Posterior – Primary $65
2381 Resin – 2 Surfaces – Posterior – Primary $90
2382 Resin – 3+ Surfaces – Posterior – Primary $105
2391 Resin – 1 Surface – Posterior – Permanent $90
2392 Resin – 2 Surfaces – Posterior – Permanent $120
2393 Resin – 3 Surfaces – Posterior – Permanent $130
2394 Resin – 4+ Surfaces – Posterior – Permanent $150
ADA Crowns (lab fees additional)  
2740 Crown – Porcelain/Ceramic Substrate $635
2750 Crown – Porcelain/High Noble Metal $595
2751 Crown – Porcelain/Predominate Base Metal $570
2752 Crown – Porcelain/Noble Metal $580
2790 Crown – Full Cast High Noble Metal $585
2791 Crown – Full Cast Predominantly Base Metal $575
2920 Re-cement Crown $50
2930 Prefabricated Stainless Steel Crown – Primary Tooth $125
2931 Prefabricated Stainless Steel Crown – Perm Tooth $140
2932 Prefab Resin Crown $155
2950 Core Buildup, Including Any Pins $110
2951 Pin Retention Per Tooth (W/O Restoration) $28
2952 Cast Post/Core (Addition to Crown) $190
2954 Prefabricated Post and Core (Addition to Crown) $150
2970 Temporary Crown (Fractured Tooth) $150
ADA Endodontics (General Dentist) exc. Final Restoration  
3220 Therapeutic Pulpotomy $69
3310 Root Canal Anterior $350
3320 Root Canal Bicuspid $430
3330 Root Canal Molar $560
ADA Prosthodontics (Performed by a General Dentist)  
4210 Gingivectomy/Gingivoplasty – 4+ contiguous teeth $315
4341 Perio. Scaling & Root Planning per Quad $125
4355 Full Mouth Debridement $75
4910 Periodontal Maintenance $80
ADA Prosthodontics, Removable (lab fees additional)  
5110 Complete Upper Denture $675
5120 Complete Lower Denture $675
5130 Immediate Upper $745
5140 Immediate Lower $745
5211 Upper Partial-Resin Base $515
5212 Lower Partial-Resin Base $515
5213 Partial Upper Cast Metal Base $699
5214 Partial Lower Cast Metal Base $699
5410 Adjust Denture (Upper) $38
5411 Adjust Denture (Lower) $38
5510 Repair Broken Complete Denture Base $95
5520 Repair Missing or Broken Teeth/Each Tooth $65
5610 Repair Resin Denture Base $85
5630 Repair or Replace Broken Clasp $80
5640 Repair Broken Teeth – Per Tooth $60
5650 Add Tooth to Existing Partial Denture $70
5660 Add Clasp to Existing Partial Denture $90
5730 Reline Upper Denture – Chairside $130
5731 Reline Lower Denture – Chairside $130
ADA Prosthodontics, Fixed (lab fees additional)  
6240 Pontic – Porcelain/High Noble Metal $525
6241 Pontic – Porcelain/Predominate Base Metal $485
6242 Pontic – Porcelain/Noble Metal $495
6750 Crown – Porcelain/High Noble Metal $545
6751 Crown – Procelain/Predominate Base Metal $495
6752 Crown – Porcelain/Noble Metal $495
6930 Re-cement Bridge $60
ADA Oral Surgery  
7140 Single Tooth Extraction $75
7120 Each Additional Extraction $55
7210 Surgical Removal of Erupted Tooth $155
7220 Removal of Impacted Tooth/Soft Tissue $145
7230 Removal of Impacted Tooth/Partially BOny $185
7240 Removal of Impacted Tooth/Completely Bony $235
7250 Surgical Removal of Residual Tooth Roots $125
7510 Incision & Drainage of Abscess/Intraoral $85
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.

  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.
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