Dental Services - Promedical Plan

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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
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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	14	D2740	Crown, porcelain (not including lab costs)	595	D5110	Upper Denture	679
D0140	Limited Oral evalution-problem focused	21	D2750	Crown, porcelain fused to high noble met (not including lab costs)	630	D5120	Lower Denture	679
D0150	Comprehensive Oral Exam	14	D2751	Crown, porcelain fused to base metal (not including lab costs)	546	D5130	Immediate upper denture	735
D0460	Pulp vitality test	21	D2752	Crown, porcelain fused to noble metal (not including lab costs)	560	D5211	Acrylic upper partial with 2 clasps	588
D0470	Diagnostic cast	42	D2790	Full cast crown, high noble metal (not including lab costs)	616	D5212	Acrylic lower partial with 2 clasps	560
D0999	Diagnosis/treatment plan presentation	0	D2791	Full cast crown, base metal (not including lab costs)	532	D5213	Base cast metal upper part. With 2 clasp acrylic saddles	686
	X-Rays		D2792 D2930	Full cast crown, noble metal (not including lab costs) Prefab, stainless steel crown, primary	560	D5124	Base cast metal lower part. With 2 clasp acrylic saddles	686
D0210	Intraoral complete series, once per 3 yrs.	42	D2931	Prefab, stainless steel crown, primary	98	D5410	Adjust compl. upper denture after 3 adjustments per adjust.	28
D0220	Periapical first film	10	D2932	Prefabricated Resin Crown	84	D5411	Adjust complete lower denture after 3 adj./adjustment	28
D0230	Periapical each additional film	7	D2940	Sedative filling	35	D5421	Adjust complete upper denture after 3 adjust per adjustment	28
D0270	Bitewing - single film, once per year	10	D2950	Core buildup, including any pins	105	D5422	Adjust complete lower denture after 3 adjust per adjustment	28
D0272	Bitewing - two films, once per year	17	D2951	Pin retention, per tooth, in addition to restore at.	28	D5510	Repair broken complete denture base	45
D0272	Bitewing - two films, once per year	12	D2952	Cast post core, in addition to crown	161	D5520	Replace missing/broken tooth on compl.dent.1 tooth	50
D0274	Bitewing - four films, once per year	21	D2954	Prefabricated post core, in addition to crown	140	D5630	Repair or replace broken clasp	45
D0274	Bitewing - four films, once per year	14	D2970	Temporary crown	105	D5640	Replace broken tooth on partial denture 1 tooth	63
D0330	Panoramic film, once per 3 years	49	D6210 D6211 D6212	Pontic, full cast, high noble metal Pontic, full cast, base metal Pontic, full cast noble metal	595 525 560	D5650 D5660 D5730 D5731	Add tooth to existing partial Add clasp to existing partial Reline upper complete, chairside Reline lower complete, chairside	81 98 84 84
	Preventive		D6240	Pontic, porcelain to high noble metal	630	D5740	Reline upper partial chairside	98
D1110	Routine Adult Prophylaxis, 1 per year	0	D6241	Pontic, porcelain to base metal	546	D5741	Reline lower partial, chairside	98
D1110	Routine Adult Prophylaxis, each additional	35	D6242	Pontic, porcelain to noble metal	560	D5750	Reline upper complete, laboratory	168
D1120	Routine child prophylaxis, 1 per year	0	D6750	Abutment, porcelain to high noble metal	560	D5751	Reline lower complete, laboratory	168
D1120	Routine child prophylaxis, each additional	28	D6751	Abutment, porcelain to base metal	525	D5760	Reline upper partial, laboratory	168
D1203	Topical application of fluoride, child	12	D6752	Abutment, porcelain to noble metal	560	D5761	Reline lower partial, laboratory	168
D1330	Oral hygiene instruction	0	D6790	Abutment, full cast, high noble metal	546	D5850	Tissue conditioning (max)	49
D1351	Sealant, per tooth, permanent posterior	14	D6791	Abutment, full cast, base metal	518	D5851	Tissue conditioning (mand)	49
D1510	Space maintainer - fixed unilateral	175	D6792	Abutment, full cast, noble metal	532		Oral Surgery (Extractions)
D1515	Space maintainer - fixed bilateral	217	D2910	Recement inlay	28	D7140	Simple extraction, first tooth	63
D1525	Space maintainer - removable bilateral	245	D2920	Recement crown	35	D7140	Simple extraction each additional tooth per treatment plan	56
	Restorative (fillings)		D6930	Recement fixed partial denture	49	D7210	Surgical extraction, erpted tooth	105
D2140	Amalgam - 1 surface, Primary Amalgam - 1 surface, Permanent	42 49		Endodontics (root canals)		D7220	Soft tissue impaction	140
D2150	Amalgam - 2 surface, Primary Amalgam - 2 surface, Permanent	56 63	D3110	Pulp cap, direct, excl. final restoration	28	D7230	Partial bony impaction	135
D2160	Amalgam - 3 surface, Primary Amalgam - 3 surface, Permanent	70 77	D3120	Pulp cap, indirect, excl. final restoration	28	D7240	Complete bony impaction	224
D2161	Amalgam - 4 surface, Primary Amalgam - 4 surface, Permanent	84 98	D3220	Pulpotomy, excluding final restoration	70	D7250	Surgical extraction of residula roots	98
D2330	Resin - 1 surface, anterior	63	D3310	Root canal, one canal	350	D7280	Surgical exposure of impacted/unerup. tooth for orth. reas.	210
D2331	Resin - 2 surface, anterior	77	D3320	Root canal, two canals	378	D7310	Alveoloplasty with extraction, per quadrant	105
D2332	Resin - 3 surface, anterior	98	D3330	Root canal, three canals	560	D7320	Alveoloplasty not in conjunction with extract. Per quadrant.	105
D2335	Resin - 4 or more or involving incisal angle , anterior	120	D3410	Apicoectomy, per tooth, anterior	350	D7471	Removal of exostosis	217
D2391	Resin - 1 surface, posterior	70		Periodontics (gum treatment)		D7510	Incision and drainage of abscess , introral	77
D2392	Resin - 2 surface, posterior	112	D4210	Gingivectomy or gingivoplasty, 4 per quadrant	245	D7960	Frenectomy, seperate procedure	175
D2393	Resin - 3 surface, posterior	140	D4211	Gingivec. or gingivopl. 3 per quad, per tooth	42	D7970	Exision of hyperplastic tissue, per arch	126
D2394	Resin - 4 or more or involving incisal angle, posterior	168	D4240	Gingival flap proced. incl. root pl. per quadrant	280		Adjunctive General Services
			D4241	Gingival flap proced. incl. root pl. 3 teeth, per quad, per tooth	49	D9110	Palliative (emergency) treatment dental pain	35
			D4260	Osseous surgery, 4+ teeth per quad	630	D9230	Analgesia, per visit	21
			D4261	Osseous surgery, up to 3 teeth per quad per tooth	105	D9430	Office visit, normal hours	0
			D4271	Free soft tissue graft, per procedure	420	D9440	Office visit, after hours	70
			D4341	Periodontal scaling & root plan, p.quad, p.quad, 4 teeth	105	D9630	Other drugs or medicaments by report	14
			D4342	Periodontal scal. & root plan. 3 t.p.quad.p.tooth	21	D9950	Occlusion analusis (mounted case)	56
			D4910	Periodontal maintenance procedures	70	D9951	Occlusal adjustment, limited	56
						D9952	Occlusal adjustment, complete	140
						D9999	Broken appt. Less than 24 hrs. notice per 15 minutes unit. (maximum $40)	14

YOUR SAVINGS

Procedure

Member Pays

Member Savings

Average Dentist Charges

Initial Oral Exam	$14.00	$77.00	$91.00
Full Mouth X-ray	$42.00	$72.00	$114.00
Bite Wing X-ray	$17.00	$38.00	$55.00
Adult Cleaning	No Charge	$84.00	$84.00
Application of Fluoride (Children Only)	$12.00	$34.00	$46.00
Sealants, Per Tooth (Children Only)	$14.00	$36.00	$50.00
3 - Surface Silver (Amalgam) Filling	$70.00	$111.00	$181.00
Porcelain and Noble Metal Crown	$560.00	$375.00	$935.00
Molar Root Canal	$560.00	$360.00	$920.00
Simple Extraction	$63.00	$73.00	$136.00
Perio Scaling and Root Planning (Full Mouth)	$420.00	$476.00	$896.00
Complete Upper Denture	$679.00	$680.00	$1,359.00
Emergency Treatment	$35.00	$80.00	$115.00

*Average dentist fees are derived from averages of dental fees with major insurance companies in the state of Florida.