2023 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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