2022 fee schedule - Coast Dental
[Pages:12]2023 FEE SCHEDULE
Diagnostic Services (Performed by a General Dentist)
ADA Code
Procedure Description
D0120 Periodic oral exam
D0140 Limited oral exam, problem-focused or emergency exam
D0150 Comprehensive oral evaluation, new or established patient
D0160 Detailed and extensive evaluation
D0170 Re-evaluation limited, problem-focused exam
D0180 Comprehensive periodontal exam
D0191 Assessment of patient
D0210 Intraoral x-rays, complete series including bitewings, 1x every 3 years
D0220 Intraoral x-ray, periapical, first film
D0230 Intraoral x-ray, periapical, each additional film
D0240 Intraoral x-ray, occlusal film
D0250 Extraoral x-ray, first film
D0260 Extraoral x-ray, each additional film
D0270 Bitewing x-ray, single film
D0272 Bitewing x-rays, two films
D0273 Bitewing x-rays, three films
D0274 Bitewing x-rays, four films
D0277 Vertical bitewing x-rays, 7 to 8 films
D0290 Posterior/Anterior or lateral skull and facial x-ray film
D0330 Panoramic x-ray film
D0350 Oral/Facial photographic images
D0416 Viral culture
D0421 Genetic test for susceptibility to oral diseases
D0425 Caries susceptibility test
D0460 Pulp vitality test
D0470 Diagnostic cast
NonMember
$59 $87 $102 $178 $86 $114 $92 $155 $35 $30 $48 $76 $66 $35 $54 $64 $77 $116 $152 $131 $83 $187 $146 $99 $66 $138
SmilePlus Member
$0 $25 $0 $90 $40 $55 $15 $0 $19 $17 $18 $24 $22 $18 $20 $32 $38 $45 $80 $45 $41 $89 $74 $68 $37 $68
SAVE 100% 71% 100% 49% 53% 52% 84% 100% 46% 43% 63% 68% 67% 49% 63% 50% 51% 61% 47% 66% 51% 52% 49% 31% 44% 51%
page 1 of 12
SMILEPLUS? is a registered trademark of Coast Dental Services, LLC., and IS NOT A REGISTERED INSURANCE PLAN. It is an annual savings plan offered exclusively to patients at Coast Dental & Orthodontics. Specialist services available in select locations and may change without notice. Contact your local office to verify. Fees effective 01/01/19 and subject to change without notice. The dentists and hygienists are employees or independent contractors of Coast Florida, P.A., Coast Dental, P.A., (Adam Diasti, DDS, DN12490), Coast Dental of Georgia, P.C., (Adam Diasti, DDS, DN11634) or Coast Dental of Texas, PC (Adam Diasti, DDS, Lic. 32327). Coast Dental Services, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ? 2023 Coast Dental All rights reserved. CD-103036 R01/23
Membership Program
2023 FEE SCHEDULE
Preventive Services (Performed by a General Dentist)
ADA Code
Procedure Description
D1110 Adult cleaning, above the gum line (Two free per year with SmilePlus Silver)
D1120 Child cleaning, above the gum line (Or two free per year with SmilePlus Silver)
D1206 Topical application of fluoride (One free per year with SmilePlus Gold)
D1351 Sealant, per tooth
D1510 Space maintainer, fixed, unilateral
D1515 Space maintainer, fixed, bilateral
D1550 Recementation of space maintainer
D1555 Removal of space maintainer
NonMember $107
$83 $54 $69 $361 $478 $99 $97
SmilePlus Member $107
$83 $54 $26 $210 $315 $58 $58
SAVE 0% 0% 0% 62% 42% 34% 41% 40%
Restorative Services (Performed by a General Dentist)
ADA Code
Procedure Description
D2330 Resin/Composite filling, one surface, anterior
D2331 Resin/Composite filling, two surfaces, anterior
D2332 Resin/Composite filling, three surfaces, anterior
D2335 Resin/Composite filling, four + surfaces, anterior
D2390 Resin/Composite crown, anterior
D2391 Resin/Composite filling, one surface, posterior
D2392 Resin/Composite filling, two surfaces, posterior
D2393 Resin/Composite filling, three surfaces, posterior
D2394 Resin/Composite filling, four + surfaces, posterior
D2510 Inlay, metallic, one surface
D2520 Inlay, metallic, two surfaces
D2530 Inlay, metallic, three surfaces
D2542 Onlay, metallic, two surfaces
D2543 Onlay, metallic, three surfaces
NonMember
$197 $239 $294 $367 $543 $212 $271 $333 $398 $1,060 $1,116 $1,165 $1,177 $1,220
SmilePlus Member
$83 $142 $194 $236 $341 $131 $179 $226 $263 $578 $630 $709 $735 $788
SAVE 58% 41% 34% 36% 37% 38% 34% 32% 34% 45% 44% 39% 38% 35%
page 2 of 12
SMILEPLUS? is a registered trademark of Coast Dental Services, LLC., and IS NOT A REGISTERED INSURANCE PLAN. It is an annual savings plan offered exclusively to patients at Coast Dental & Orthodontics. Specialist services available in select locations and may change without notice. Contact your local office to verify. Fees effective 01/01/19 and subject to change without notice. The dentists and hygienists are employees or independent contractors of Coast Florida, P.A., Coast Dental, P.A., (Adam Diasti, DDS, DN12490), Coast Dental of Georgia, P.C., (Adam Diasti, DDS, DN11634) or Coast Dental of Texas, PC (Adam Diasti, DDS, Lic. 32327). Coast Dental Services, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ? 2023 Coast Dental All rights reserved. CD-103036 R01/23
Membership Program
2023 FEE SCHEDULE
Restorative Services (Performed by a General Dentist)
ADA Code
Procedure Description
D2544 Onlay, metallic, four + surfaces
D2610 Inlay, porcelain/ceramic, one surface
D2620 Inlay, porcelain/ceramic, two surfaces
D2630 Inlay, porcelain/ceramic, three surfaces
D2642 Onlay, porcelain/ceramic, two surfaces
D2643 Onlay, porcelain/ceramic, three surfaces
D2644 Onlay, porcelain/ceramic, four + surfaces
D2740 Crown, porcelain/ceramic, Zirconia
D2750 Crown, porcelain fused to high noble metal
D2751 Crown, porcelain fused to predominantly base metal
D2752 Crown, porcelain fused to noble metal
D2780 Crown, 3/4 cast high noble metal
D2783 Crown, 3/4 porcelain/ceramic
D2790 Crown, full cast high noble metal
D2791 Crown, full cast predominantly base metal
D2792 Crown, full cast noble metal
D2794 Crown, titanium
D2799 Provisional crown
D2910 Recement inlays/onlays
D2915 Recement cast or prefabricated post & core
D2920 Recement crowns
D2930 Prefabricated stainless steel crown, primary
D2931 Prefabricated stainless steel crown, permanent
D2932 Prefabricated resin crown
D2950 Core buildup, including any pins
NonMember $1,263 $1,123 $1,145 $1,216 $1,205 $1,234 $1,284 $1,454 $1,319 $1,127 $1,174 $1,284 $1,284 $1,269 $1,113 $1,170 $1,291
$519 $136 $138 $133 $311 $359 $411 $309
SmilePlus Member $814 $551 $578 $604 $735
$761 $814 $799 $785 $578 $630 $788 $814 $814 $551 $656 $814 $210 $79 $79 $79 $184 $236 $236 $158
SAVE 36% 51% 50% 50% 39% 38% 37% 45% 40% 49% 46% 39% 37% 36% 50% 44% 37% 60% 42% 43% 41% 41% 34% 43% 49%
page 3 of 12
SMILEPLUS? is a registered trademark of Coast Dental Services, LLC., and IS NOT A REGISTERED INSURANCE PLAN. It is an annual savings plan offered exclusively to patients at Coast Dental & Orthodontics. Specialist services available in select locations and may change without notice. Contact your local office to verify. Fees effective 01/01/19 and subject to change without notice. The dentists and hygienists are employees or independent contractors of Coast Florida, P.A., Coast Dental, P.A., (Adam Diasti, DDS, DN12490), Coast Dental of Georgia, P.C., (Adam Diasti, DDS, DN11634) or Coast Dental of Texas, PC (Adam Diasti, DDS, Lic. 32327). Coast Dental Services, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ? 2023 Coast Dental All rights reserved. CD-103036 R01/23
Membership Program
2023 FEE SCHEDULE
Restorative Services (Performed by a General Dentist)
ADA Code
Procedure Description
D2951 Pin retention, per tooth, in addition to restoration
D2952 Post & core, in addition to crown
D2954 Prefabricated post & core, in addition to crown
D2955 Post removal, not in conjunction with endo therapy
D2962 Labial veneer, porcelain laminate, laboratory
D2971 Crown construction under partial
D2980 Crown repair
Endodontic Services (Performed by a General Dentist)
ADA Code
D3110
Procedure Description Pulp cap, direct, excluding final restoration
D3120 Pulp cap, indirect, excluding final restoration
D3220 Therapeutic pulpotomy, excluding final restoration
D3221 Gross pulpal debridement, primary and permanent teeth
D3240 Pulpal therapy, posterior, primary, excluding final restoration
D3310 Anterior root canal, excluding final restoration
D3320 Bicuspid root canal, excluding final restoration
D3330 Molar root canal, excluding final restoration
D3331 Treatment of root canal obstructions, non-surgical access
D3332 Incomplete endo therapy, unrestorable tooth
D3346 Retreatment of root canal, anterior
D3347 Retreatment of root canal, bicuspid
D3348 Retreatment of root canal, molar
D3920 Hemisection, including any root removal
NonMember
$91 $476 $387 $341 $1,347 $286 $339
SmilePlus Member
$47 $315 $210 $228 $814 $79 $184
SAVE 48% 34% 46% 33% 40% 72% 46%
NonMember
$98 $98 $242 $272 $352 $886 $999 $1,219 $754 $523 $1,007 $1,138 $1,382 $543
SmilePlus Member
$53 $53 $126 $158 $236 $509 $625 $709 $210 $318 $630 $683 $840 $373
SAVE 46% 46% 48% 42% 33% 43% 37% 42% 72% 39% 37% 40% 39% 31%
page 4 of 12
SMILEPLUS? is a registered trademark of Coast Dental Services, LLC., and IS NOT A REGISTERED INSURANCE PLAN. It is an annual savings plan offered exclusively to patients at Coast Dental & Orthodontics. Specialist services available in select locations and may change without notice. Contact your local office to verify. Fees effective 01/01/19 and subject to change without notice. The dentists and hygienists are employees or independent contractors of Coast Florida, P.A., Coast Dental, P.A., (Adam Diasti, DDS, DN12490), Coast Dental of Georgia, P.C., (Adam Diasti, DDS, DN11634) or Coast Dental of Texas, PC (Adam Diasti, DDS, Lic. 32327). Coast Dental Services, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ? 2023 Coast Dental All rights reserved. CD-103036 R01/23
Membership Program
2023 FEE SCHEDULE
Periodontic Services (Performed by a General Dentist)
ADA Code
D4210
Procedure Description Gingivectomy or gingivoplasty, 4 + bound teeth per quadrant
D4211 Gingivectomy or gingivoplasty, 1 to 3 teeth
D4212
Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth
D4230 Anatomical crown exposure, 4 + bound teeth per quadrant
D4231 Anatomical crown exposure, 1 to 3 teeth
D4240 Gingival flap procedure, 4 + bound teeth per quadrant
D4241 Gingival flap procedure, including root planing, 1 to 3 teeth
D4245 Apically positioned flap
D4249 Crown lengthening, hard and soft tissue
D4260 Osseous surgery, 4 + teeth per quadrant
D4261 Osseous surgery, 1 to 3 teeth
D4263 Bone replacement, first site
D4264 Bone replacement graft, each additional site in quadrant
D4266 Guided tissue regeneration, resorbable barrier
D4267 Guided tissue regeneration, nonresorbable barrier
D4268 Surgical revision procedure, per tooth
D4270 Pedicle soft tissue graft
D4271 Free soft tissue graft
D4274 Distal or proximal wedge procedure
D4276 Combined connective tissue and double pedicle graft
D4277 Free soft tissue graft procedure
D4320 Provisional splinting, intracoronal
D4321 Provisional splinting, extracoronal
D4341 Periodontal scaling and root planing, 4 + teeth per quadrant
D4342 Periodontal scaling and root planing, 1 to 3 teeth
NonMember $736 $385
$346
$985 $696 $858 $702 $938 $902 $1,311 $1,058 $785 $636 $889 $1,024 $941 $988 $865 $773 $1,300 $1,160 $607 $548 $296 $222
SmilePlus Member $473
$168
SAVE 36% 56%
$100
71%
$368 $341 $572 $499 $625 $525 $840 $656 $473 $341 $630 $772 $630 $630 $630 $536 $893 $630 $368 $341 $135 $93
63% 51% 33% 29% 33% 42% 36% 38% 40% 46% 29% 25% 33% 36% 27% 31% 31% 46% 39% 38% 54% 58%
page 5 of 12
SMILEPLUS? is a registered trademark of Coast Dental Services, LLC., and IS NOT A REGISTERED INSURANCE PLAN. It is an annual savings plan offered exclusively to patients at Coast Dental & Orthodontics. Specialist services available in select locations and may change without notice. Contact your local office to verify. Fees effective 01/01/19 and subject to change without notice. The dentists and hygienists are employees or independent contractors of Coast Florida, P.A., Coast Dental, P.A., (Adam Diasti, DDS, DN12490), Coast Dental of Georgia, P.C., (Adam Diasti, DDS, DN11634) or Coast Dental of Texas, PC (Adam Diasti, DDS, Lic. 32327). Coast Dental Services, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ? 2023 Coast Dental All rights reserved. CD-103036 R01/23
Membership Program
2023 FEE SCHEDULE
Periodontic Services (Performed by a General Dentist)
ADA Code
D4355
Procedure Description Full mouth debridement to enable evaluation and diagnosis
D4910 Periodontal maintenance (Three free per year with SmilePlus Gold)
D4381 Initial Minocycline, localized delivery
D4381 Minocycline, additional site, same tooth
NonMember $210
$159 $151 $20
SmilePlus Member $104
$159 $121 $20
SAVE 50% 0% 20% 0%
Removable Prosthodontic Services (Performed by a General Dentist)
ADA Code
D5110
Procedure Description Deluxe denture, upper
NonMember
$2,271
D5110 Elite denture, upper
$2,271
D5110 Premier denture, upper
$999
D5120 Deluxe denture, lower
$2,272
D5120 Elite denture, lower
$2,272
D5120 Premier denture, lower
$999
D5130 Immediate Premier denture, upper
$1,099
D5130 Immediate Deluxe denture, upper
$2,385
D5130 Immediate Elite denture, upper
$2,385
D5140 Immediate Premier denture, lower
$1,099
D5140 Immediate Deluxe denture, lower
$2,419
D5140 Immediate Elite denture, lower
$2,419
D5211 Partial, upper, resin base
$899
D5212 Partial, lower, resin base
$1,629
D5213 Deluxe partial, upper
$2,320
D5214 Deluxe partial, lower
$2,320
D5213 Elite partial, upper
$2,121
D5214 Elite partial, lower
$2,128
SmilePlus Member
$699
SAVE 69%
$799
65%
$899
10%
$699
69%
$799
65%
$899
10%
$999
9%
$799
66%
$899
62%
$999
9%
$799
67%
$899
63%
$650
28%
$650
60%
$656
72%
$656
72%
$998
53%
$998 53%
page 6 of 12
SMILEPLUS? is a registered trademark of Coast Dental Services, LLC., and IS NOT A REGISTERED INSURANCE PLAN. It is an annual savings plan offered exclusively to patients at Coast Dental & Orthodontics. Specialist services available in select locations and may change without notice. Contact your local office to verify. Fees effective 01/01/19 and subject to change without notice. The dentists and hygienists are employees or independent contractors of Coast Florida, P.A., Coast Dental, P.A., (Adam Diasti, DDS, DN12490), Coast Dental of Georgia, P.C., (Adam Diasti, DDS, DN11634) or Coast Dental of Texas, PC (Adam Diasti, DDS, Lic. 32327). Coast Dental Services, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ? 2023 Coast Dental All rights reserved. CD-103036 R01/23
Membership Program
2023 FEE SCHEDULE
Removable Prosthodontic Services (Performed by a General Dentist)
ADA Code
D5213
Procedure Description Premier partial, upper
D5214 Premier partial, lower
D5225 Partial denture with flexible base, upper
D5226 Partial denture with flexible base, lower
D5213 Immediate Deluxe partial, upper
D5214 Immediate Deluxe partial, lower
D5225 Cosmetic partial, Valplast?, upper
D5226 Cosmetic partial, Valplast?, lower
D5213 Combination partial, upper, metal base and clear clasp
D5214 Combination partial, lower, metal base and clear clasp
D5281 Removable unilateral partial denture, one piece
D5410 Adjust complete denture, upper
D5411 Adjust complete denture, lower
D5421 Adjust partial denture, upper
D5422 Adjust partial denture, lower
D5510 Repair broken complete denture base
D5520 Replace missing or broken teeth, complete denture
D5610 Repair acrylic saddle or base
D5620 Repair cast framework
D5630 Repair or replace broken clasp
D5640 Replace broken teeth, per tooth
D5650 Add tooth to existing partial denture
D5660 Add clasp to existing partial denture
D5670 Replace all teeth and acrylic on cast metal framework, upper
D5671 Replace all teeth and acrylic on cast metal framework, lower
NonMember $2,121 $2,128 $1,827 $1,820 $2,121 $2,128 $1,851 $1,825 $2,121 $2,128 $1,201
$107 $106 $106 $106 $259 $226 $245 $343 $317 $231 $272 $319 $871 $884
SmilePlus Member
$1,155
SAVE 46%
$1,155 46%
$866 53%
$866 52%
$839 60%
$839 61%
$1,103 40%
$1,103 40%
$1,313 38%
$1,313 38%
$814 32%
$53 50%
$53 50%
$53 50%
$53 50%
$142 45%
$104 54%
$142 42%
$179 48%
$168 47%
$104 55%
$135 50%
$188 41%
$499 43%
$499 44%
page 7 of 12
SMILEPLUS? is a registered trademark of Coast Dental Services, LLC., and IS NOT A REGISTERED INSURANCE PLAN. It is an annual savings plan offered exclusively to patients at Coast Dental & Orthodontics. Specialist services available in select locations and may change without notice. Contact your local office to verify. Fees effective 01/01/19 and subject to change without notice. The dentists and hygienists are employees or independent contractors of Coast Florida, P.A., Coast Dental, P.A., (Adam Diasti, DDS, DN12490), Coast Dental of Georgia, P.C., (Adam Diasti, DDS, DN11634) or Coast Dental of Texas, PC (Adam Diasti, DDS, Lic. 32327). Coast Dental Services, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ? 2023 Coast Dental All rights reserved. CD-103036 R01/23
Membership Program
2023 FEE SCHEDULE
Removable Prosthodontic Services (Performed by a General Dentist)
ADA Code
D5710
Procedure Description Rebase, complete upper denture
D5711 Rebase, complete lower denture
D5720 Rebase, upper partial denture
D5721 Rebase, lower partial denture
D5730 Reline, upper complete denture, chairside
D5731 Reline, lower complete denture, chairside
D5740 Reline, upper partial denture, chairside
D5741 Reline, lower partial denture, chairside
D5750 Reline, upper complete denture, laboratory
D5751 Reline, lower complete denture, laboratory
D5760 Reline, upper partial denture, laboratory
D5761 Reline, lower partial denture, laboratory
D5810 Denture, temporary, complete upper
D5811 Denture, temporary, complete lower
D5820 Interim partial denture (flipper), upper
D5821 Interim partial denture (flipper), lower
D5850 Tissue conditioning, upper denture
D5851 Tissue conditioning, lower denture
D5860 Overdenture complete
D5861 Overdenture partial
D5862 Precision attachment
D5867 Replacement of semi-precision or precision attachment
D5982 Surgical stent
NonMember
$692 $691 $666 $666 $444 $444 $434 $440 $543 $558 $545 $548 $1,029 $1,037 $839 $839 $247 $247 $2,048 $1,997 $838 $469 $528
SmilePlus Member
$378
SAVE 45%
$378 45%
$378 43%
$378 43%
$221 50%
$221 50%
$221 49%
$221 50%
$289 47%
$289 48%
$289 47%
$289 47%
$499 52%
$499 52%
$419 50%
$419 50%
$137 45%
$137 45%
$1,260 38%
$1,260 37%
$420 50%
$105 78%
$294 44%
page 8 of 12
SMILEPLUS? is a registered trademark of Coast Dental Services, LLC., and IS NOT A REGISTERED INSURANCE PLAN. It is an annual savings plan offered exclusively to patients at Coast Dental & Orthodontics. Specialist services available in select locations and may change without notice. Contact your local office to verify. Fees effective 01/01/19 and subject to change without notice. The dentists and hygienists are employees or independent contractors of Coast Florida, P.A., Coast Dental, P.A., (Adam Diasti, DDS, DN12490), Coast Dental of Georgia, P.C., (Adam Diasti, DDS, DN11634) or Coast Dental of Texas, PC (Adam Diasti, DDS, Lic. 32327). Coast Dental Services, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ? 2023 Coast Dental All rights reserved. CD-103036 R01/23
Membership Program
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