Dental Plan

Prices and Details About Different Dental Services

Central Florida Dental Plan (C.F.D.P.) Schedule of Benefits
ADA Code Procedure
Appointments

9430 Office Visit (Normal Hours)/Infection Control

$ 10.00

9430 Emergency Visit (Regular Hours)

$ 25.00

ADA Code Procedure
Prosthodontics
Standard Complete Dentures

5110 Complete Maxillary (Upper) Elite Teeth

$ 595.00

5120 Complete Mandibular (Lower) Elite Teeth

$ 595.00

5130 Immediate Maxillary (Upper) Elite Teeth

$ 695.00

5140 Immediate Mandibular (Lower) Elite Teeth

$ 695.00

Diagnostic

0140/0150/0160 Oral Evaluation (Exam)

$ 15.00

0120 Periodic Oral evaluation (Exam)

0470 Diagnostic Casts (Study Models)

0999 Diagnosis and Treatment Plan Presentation

9310 Consultation

0460 Pulp Vitality Tests

Partial Dentures

5225/5226 Maxillay/mandibular Valplast Partial

$ 1100.00

5213/5214 Maxillary/mandibular Cast Metal Partial

$ 895.00

5410/5411 Adjust Complete-Maxillary/Mandibular

No Charge

5421/5422 Adjust Partial Denture-Maxillary/Mandibular

No Charge

Radiographs

0210 Intraoral – Complete Series

0220 Intraoral – Periapical – First Film

0230 Intraoral – Periapical – Each Additional Film

0270 Bitewings – Single Film

0272 Bitewings – Two Films

0274 Bitewings – Four Films

0330 Panoramic

Repairs to Prosthetics

5510/5610 Repair Broken Resin Denture Base

$ 125.00

5520/5640 Replace Missing or Broken Teeth (Each Tooth)

$ 125.00

5520/5460 Each Additional Tooth

$ 95.00

5630 Repair or Replace Broken Clasps

$ 95.00

5650 Add Tooth to Existing Partial Denture

$ 175.00

5850/5851 Tissue Conditioning

No Charge

5730/5731/5740/5741 Relining (Chairside)

$ 125.00

5750/5751/576015761 Relining (Laboratory)

$ 195.00

5710/5711 Rebase (Laboratory)

$ 250.00

Preventative

1110/1120 Prophylaxis (Routine, Once Every 6 Months)

1110/1120 Additional Prophylaxis

1201/1203 Topical Application of Flouride 1351 Sealant – Per Tooth

1330 Oral Hygiene Instruction

1999 Teeth Whiting (In Office)

1999 Teeth Whiting (Home Kit)

Dental Implants

6010 Full-Size Implants

$ 1000.00

6013 Mini Implants

$ 750.00

6056 Implant Abutment

$ 750.00

6059 Implant Attachment

$ 600.00

Restorative

2999 Sedative Base (Under Filings)

Amalgam (Silver)

2110/2140 One Surface Posterior

2120/2150 Two surfaces Posterior

2130/2160 Three surfaces Posterior

2131/2161 Four surfaces Posterior Resin restoration

2300 Anterior One Surface

2331 Anterior Two Surface

2332 Anterior Three Surfaces

2335 Anterior Four Surfaces

Extractions/Oral Surgery

7110 Single Tooth

$ 175.00

7120 Each Additional Tooth (Per Visit)

$ 125.00

7130 Root Removal-Exposed Root

$ 125.00

7210 Surgical Extraction Of Erupted Tooth

$ 195.00

7220 Soft Tissue Impaction

$ 175.00

7230 Partially Bony Impaction

$ 115.00

7240 Completely Bony Impaction

$ 250.00

7250 Surgical Removal of Residual Tooth Roots

$ 125.00

7310 Alveoloplasty In Conjunction With Extractions – Per Quadrant

$ 125.00

7320 Alveoplasty Not In Conjunction With Extractions – Per Quadrant

$ 195.00

Crown and Bridge

2930 Prefabricated Stainless Steel-Primary Tooth

2751/6241 Porcelain Fused to Metal Crown (N.P.)

2752/6242 Porcelain Fused to Metal Crown (S.P.)

2790/6210 Gold Crowns

Anesthesia

9215 Local Anesthesia

No Charge

9230 Analgesia (Nitrous Oxide – Per 15 min)

$ 35.00

Pontics

6210/6211/6212 Full Cas Pontic (Gold)

6241 Porcelain Fused to Metal Pontic (N.P.)

6242 Porcelain Fused to Metal Pontic (S.P.)

2950 Core Buildup 2951 Pin Retention – Per Tooth

2952 Cast Post and Core

2954 Prefabricated Post and Core

2910/2920/6930 Recement Inlay/Onlay/Crown/Bridge (Per Unit)

Orthodontics

Benefits for Orthodontics (Braces) for Adults and Children Is Available at a 25% Discount of UCR.

Adjunctive Services

9951 Occlusal Adjustment – Limited

$ 75.00

9952 Occlusal Adjustment – Complete

$ 275.00

Endontics

3220 Therapeutic Pulpotomy Root Canals

3310 Anterior

3320 Bicuspid

3330 Molar

3410 Apicoectomy (Anterior Only)

Periodontics

4210 Gingivectomy/Gingivoplasty – Per Quadrant

$ 250.00

4211 Gingivectomy/Gingivoplasty – Per Tooth

$ 75.00

4220 Gingival Curettage, Surgical – Per Quadrant

$ 250.00

4249 Clinical Crown Lengthening – Per Tooth

$ 195.00

4263 Bone Graft

$ 350.00

4266 Membrane Graff

$ 250.00

4341 Periodontal scaling and root planning – per quad

$ 125.00

4355 Full Mouth Debridement (Gross Scale)

$ 75.00

4381 Localized Delivery Of Chemotherapeutic Agent

$ 40.00

4910 Periodontal Maintenance Procedures

$ 60.00
dental-patient

Dental Procedure

Since most all dental procedures are performed in-house at each location, a referral to a local specialist is available but not usually necessary, and any fees charged by the specialist are the patient's responsibility.

This is an in-house discount dental plan and does not apply to any outside offices or specialists.
25% discount off UCR for procedures not listed here:

  • No Enrollment Fee
  • No Yearly Max
  • No Deductibles
  • No Administrative Fees
  • No Claim Forms To File
  • No Waiting Period for Major Services
  • No Hidden Costs