Dental Services - Promedical Plan

The Best Dental Plan.

Our mission is to exceed the needs of our members, participating dentists and agents by providing exceptional customer service and by promoting the delivery of cost effective quality dental care. We strive to promote oral health to the greatest number of people by providing accessible dental benefit of the highest quality, service, and value.

ProDental Plus now offers more. Click the blue links below to learn more about our current and newly added services.

Schedule of Benefits
Your Savings
Pharmacy Card
Hearing Aids
Vision Care
Diabetic Supplies

SCHEDULE OF BENEFITS

Code	Diagnostic	Member Pays	Code	Fixed Crown and Bridge	Member Pays	Code	Removable Prosthodontics (Dentures, Partials)	Member Pays
D0120	Periodic Oral Exam	10	D2740	Crown, porcelain	425	D5110	Upper Denture	485
D0140	Limited Oral evalution-problem focused	15	D2750	Crown, porcelain fused to high noble met.	450	D5120	Lower Denture	485
D0150	Comprehensive Oral Exam	10	D2751	Crown, porcelain fused to base metal	390	D5130	Immediate upper denture	525
D0460	Pulp vitality test	15	D2752	Crown, porcelain fused to noble metal	400	D5211	Acrylic upper partial with 2 clasps	420
D0470	Diagnostic cast	30	D2790	Full cast crown, high noble metal	440	D5212	Acrylic lower partial with 2 clasps	400
D0999	Diagnosis/treatment plan presentation	0	D2791	Full cast crown, base metal	380	D5213	Base cast metal upper part. With 2 clasp acrylic saddles	490
	X-Rays		D2792 D2930	Full cast crown, noble metal Prefab, stainless steel crown, primary	400	D5124	Base cast metal lower part. With 2 clasp acrylic saddles	490
D0210	Intraoral complete series, once per 3 yrs.	30	D2931	Prefab, stainless steel crown, primary	50	D5410	Adjust compl. upper denture after 3 adjustments per adjust.	20
D0220	Periapical first film	7	D2932	Prefabricated Resin Crown	60	D5411	Adjust complete lower denture after 3 adj./adjustment	20
D0230	Periapical each additional film	5	D2940	Sedative filling	25	D5421	Adjust complete upper denture after 3 adjust per adjustment	20
D0270	Bitewing - single film, once per year	7	D2950	Core buildup, including any pins	75	D5422	Adjust complete lower denture after 3 adjust per adjustment	20
D0272	Bitewing - two films, once per year	12	D2951	Pin retention, per tooth, in addition to restore at.	20	D5510	Repair broken complete denture base	45
D0272	Bitewing - two films, once per year	8	D2952	Cast post core, in addition to crown	115	D5520	Replace missing/broken tooth on compl.dent.1 tooth	50
D0274	Bitewing - four films, once per year	15	D2954	Prefabricated post core, in addition to crown	100	D5630	Repair or replace broken clasp	45
D0274	Bitewing - four films, once per year	10	D2970	Temporary crown	75	D5640	Replace broken tooth on partial denture 1 tooth	50
D0330	Panoramic film, once per 3 years	35	D6210 D6211 D6212	Pontic, full cast, high noble metal Pontic, full cast, base metal Pontic, full cast noble metal	425 375 400	D5650 D5660 D5730 D5731	Add tooth to existing partial Add clasp to existing partial Reline upper complete, chairside Reline lower complete, chairside	58 70 60 60
	Preventive		D6240	Pontic, porcelain to high noble metal	450	D5740	Reline upper partial chairside	70
D1110	Routine Adult Prophylaxis, 1 per year	0	D6241	Pontic, porcelain to base metal	390	D5741	Reline lower partial, chairside	70
D1110	Routine Adult Prophylaxis, each additional	25	D6242	Pontic, porcelain to noble metal	400	D5750	Reline upper complete, laboratory	120
D1120	Routine child prophylaxis, 1 per year	0	D6750	Abutment, porcelain to high noble metal	400	D5751	Reline lower complete, laboratory	120
D1120	Routine child prophylaxis, each additional	20	D6751	Abutment, porcelain to base metal	375	D5760	Reline upper partial, laboratory	120
D1203	Topical application of fluoride, child	8	D6752	Abutment, porcelain to noble metal	400	D5761	Reline lower partial, laboratory	120
D1330	Oral hygiene instruction	0	D6790	Abutment, full cast, high noble metal	390	D5850	Tissue conditioning (max)	35
D1351	Sealant, per tooth, permanent posterior	10	D6791	Abutment, full cast, base metal	370	D5851	Tissue conditioning (mand)	35
D1510	Space maintainer - fixed unilateral	125	D6792	Abutment, full cast, noble metal	380		Oral Surgery (Extractions)
D1515	Space maintainer - fixed bilateral	155	D2910	Recement inlay	20	D7140	Simple extraction, first tooth	45
D1525	Space maintainer - removable bilateral	175	D2920	Recement crown	25	D7140	Simple extraction each additional tooth per treatment plan	40
	Restorative (fillings)		D6930	Recement fixed partial denture	35	D7210	Surgical extraction, erpted tooth	75
D2140	Amalgam - 1 surface, Primary Amalgam - 1 surface, Permanent	30 35		Endodontics (root canals)		D7220	Soft tissue impaction	100
D2150	Amalgam - 2 surface, Primary Amalgam - 2 surface, Permanent	40 45	D3110	Pulp cap, direct, excl. final restoration	20	D7230	Partial bony impaction	135
D2160	Amalgam - 3 surface, Primary