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 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