General Dentist Fee Schedule

As an SDP 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	$17
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
1204	Topical Fluoride Application	$15
1351	Topical Sealants – Per Tooth	$24

ADA	Restorative (fillings)
2110	Amalgam – 1 Surface, Primary	$52
2120	Amalgam – 2 Surfaces, Primary	$65
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
2960	Labial Veneer (Resin-Laminate) Chairside	$279
2961	Labial Veneer (Resin-Laminate) Laboratory	$400
2962	Labial Veneer (Porcelain-Laminate) Laboratory	$469
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
4260	Osseous Surgery (W/ Flap Entry & Closure) P/Quad	$455
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 SDP 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:
SDP Dental Plan is a discount dental plan, NOT INSURANCE. SDP 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.