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	23	D2740	Crown, porcelain (not including lab costs)	625	D5110	Upper Denture	700
D0140	Limited Oral evalution-problem focused	54	D2750	Crown, porcelain fused to high noble met (not including lab costs)	620	D5120	Lower Denture	700
D0150	Comprehensive Oral Exam	55	D2751	Crown, porcelain fused to base metal (not including lab costs)	570	D5130	Immediate upper denture	780
D0460	Pulp vitality test	26	D2752	Crown, porcelain fused to noble metal (not including lab costs)	590	D5140	Immediate upper denture	780
D0470	Diagnostic cast	55	D2790	Full cast crown, high noble metal (not including lab costs)	590	D5211	Acrylic upper partial with 2 clasps	610
D0999	Diagnosis/treatment plan presentation	0	D2791	Full cast crown, base metal (not including lab costs)	570	D5212	Acrylic lower partial with 2 clasps	670
	X-Rays		D2792 D2930	Full cast crown, noble metal (not including lab costs) Prefab, stainless steel crown, primary	570 140	D5213	Base cast metal upper part. With 2 clasp acrylic saddles	790
D0210	Intraoral complete series, once per 3 yrs.	67	D2931	Prefab, stainless steel crown, permenant	160	D5124	Base cast metal lower part. With 2 clasp acrylic saddles	790
D0220	Periapical first film	13	D2932	Prefabricated esthetic coat stainless steel crown	230	D5410	Adjust compl. upper denture after 3 adjustments per adjust.	42
D0230	Periapical each additional film	11	D2940	Sedative filling	55	D5411	Adjust complete lower denture after 3 adj./adjustment	42
D0270	Bitewing - single film, once per year	14	D2950	Core buildup, including any pins	128	D5421	Adjust complete upper denture after 3 adjust per adjustment	42
D0272	Bitewing - two films, once per year	22	D2951	Pin retention, per tooth, in addition to restore at.	30	D5422	Adjust complete lower denture after 3 adjust per adjustment	42
D0273	Bitewing - three films, once per year	27	D2952	Cast post core, in addition to crown	210	D5510	Repair broken complete denture base	80
D0274	Bitewing - four films, once per year	32	D2954	Prefabricated post core, in addition to crown	168	D5520	Replace missing/broken tooth on compl.dent.1 tooth	67
D0277	Vertical Bitewings - 7 to 8 Films	48	D2970	Temporary crown	105	D5630	Repair or replace broken clasp	115
D0330	Panoramic film	60	D6210 D6211 D6212	Pontic, full cast, high noble metal Pontic, full cast, base metal Pontic, full cast noble metal	570 550 570	D5640	Replace broken tooth on partial denture 1 tooth	72
	Preventive		D6240	Pontic, porcelain to high noble metal	580	D5650 D5660 D5730 D5731	Add tooth to existing partial Add clasp to existing partial Reline upper complete, chairside Reline lower complete, chairside	100 120 170 170
D1110	Routine Adult Prophylaxis, 1 per year	47	D6241	Pontic, porcelain to base metal	510	D5740	Reline upper partial chairside	155
D1120	Routine child Prophylaxis	33	D6242	Pontic, porcelain to noble metal	540	D5741	Reline lower partial, chairside	155
D1203	Tropical Application of flouride, child	18	D6750	Abutment, porcelain to high noble metal	640	D5750	Reline upper complete, laboratory	220
D1120	Tropical Application of flouride, adult	18	D6751	Abutment, porcelain to base metal	570	D5751	Reline lower complete, laboratory	220
D1206	Topical fluoride varnish	28	D6752	Abutment, porcelain to noble metal	590	D5760	Reline upper partial, laboratory	220
D1351	Sealant, per tooth, permanent posterior	29	D6790	Abutment, full cast, high noble metal	590	D5761	Reline lower partial, laboratory	220
D1510	Space maintainer - fixed unilateral	181	D6791	Abutment, full cast, base metal	570	D5850	Tissue conditioning (max)	70
D1515	Space maintainer - fixed bilateral	242	D6792	Abutment, full cast, noble metal	570	D5851	Tissue conditioning (mand)	70
D1520	Space maintainer - removable unilateral	255	D2910	Recement inlay	51		Oral Surgery (Extractions)
D1525	Space maintainer - removable bilateral	310	D2920	Recement crown	51	D7140	Simple extraction, first tooth	72
	Restorative (fillings)		D6930	Recement fixed partial denture	72	D7140	Simple extraction each additional tooth per treatment plan	72
D2140 D2150	Amalgam - 1 surface, Primary or Permenant Amalgam - 2 surfaces, Primary or Permanent	63 79		Endodontics (root canals)		D7210	Surgical extraction, erpted tooth	129
D2160 D2161	Amalgam - 3 surfaces, Primary or Permenant Amalgam - 4 surfaces, Primary or Permanent	97 121	D3110	Pulp cap, direct, excl. final restoration	39	D7220	Soft tissue impaction	156
D2330	Resin - 1 surface, anterior	75	D3120	Pulp cap, indirect, excl. final restoration	30	D7230	Partial bony impaction	218
D2331	Resin - 2 surface, anterior	96	D3220	Pulpotomy, excluding final restoration	91	D7240	Complete bony impaction	257
D2332	Resin - 3 surface, anterior	118	D3310	Root canal, one canal	560	D7250	Surgical extraction of residula roots	147
D2335	Resin - 4 or more or involving incisal angle , anterior	134	D3320	Root canal, two canals	640	D7280	Surgical exposure of impacted/unerup. tooth for orth. reas.	310
D2390	Resin - based composit crown anterior	160	D3330	Root canal, three canals	810	D7310	Alveoloplasty with extraction, per quadrant	156
D2391	Resin - 1 surface, posterior	88	D3410	Apicoectomy, per tooth, anterior	590	D7320	Alveoloplasty not in conjunction with extract. Per quadrant.	300
D2392	Resin - 2 surface, posterior	115		Periodontics (gum treatment)		D7471	Removal of exostosis	530
D2393	Resin - 3 surface, posterior	145	D4210	Gingivectomy or gingivoplasty, 4 per quadrant	360	D7510	Incision and drainage of abscess , introral	84
D2394	Resin - 4 or more or involving incisal angle, posterior	175	D4211	Gingivec. or gingivopl. 3 per quad, per tooth	123	D7960	Frenectomy, seperate procedure	320
D2510	Inlay - Metallic - one surface	420	D4240	Gingival flap proced. incl. root pl. per quadrant	430	D7970	Exision of hyperplastic tissue, per arch	330
D2510	Inlay - Metallic - two surfaces	470	D4241	Gingival flap proced. incl. root pl. 3 teeth, per quad, per tooth	260		Adjunctive General Services
D2510	Inlay - Metallic - three or more surfaces	560	D4260	Osseous surgery, 4+ teeth per quad	620	D9110	Palliative (emergency) treatment dental pain	68
			D4261	Osseous surgery, up to 3 teeth per quad per tooth	370	D9230	Analgesia, per visit	30
			D4271	Free soft tissue graft, per procedure	520	D9430	Office visit, normal hours	37
			D4341	Periodontal scaling & root plan, p.quad, p.quad, 4 teeth	123	D9440	Office visit, after hours	69
			D4342	Periodontal scal. & root plan. 3 t.p.quad.p.tooth	70	D9950	Occlusion analusis (mounted case)	56
			D4910	Periodontal maintenance procedures	72	D9951	Occlusal adjustment, limited	70
						D9952	Occlusal adjustment, complete	390

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YOUR SAVINGS

Procedure	Member Pays	Member Savings	Average Dentist Charges *
Initial Oral Exam	$55.00	$36.00	$91.00
Full Mouth X-ray	$67.00	$47.00	$114.00
Bite Wing X-ray	$22.00	$33.00	$55.00
Adult Cleaning	$47.00	$37.00	$84.00
Application of Fluoride (Children Only)	$18.00	$28.00	$46.00
Sealants, Per Tooth (Children Only)	$29.00	$21.00	$50.00
3 - Surface Silver (Amalgam) Filling	$97.00	$84.00	$181.00
3 - Surface Silver (Resin) Filling	$145.00	$76.00	$221.00
Porcelain and Noble Metal Crown	$590.00	$345.00	$935.00
Molar (3) Root Canal	$810.00	$210.00	$1020.00
Simple Extraction (First)	$72.00	$64.00	$136.00
Perio Scaling and Root Planning (Full Mouth)	$520.00	$376.00	$896.00
Complete Upper Denture	$700.00	$659.00	$1,359.00
Emergency Treatment	$68.00	$47.00	$115.00
Comprehensive Orthodontic Treatment (Children)	$3,750.00	$1,550.00	$5,300.00

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