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