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Orthodontic Fee Schedule
ORTHODONTIC
BENEFITS
Phase One: Interceptive
Orthodontic Treatment, 20% discount off
Usual and Customary
Charges.
Phase Two:
Eruption of Permanent Teeth (pre & post).
$3195 for Class 1, adolescent only, 24
months of treatment, (includes study models and records fee).
Class 2, 3, 4, adult, surgical or
more complex cases will receive 20% discount
off usual and customary charges.
The total costs of orthodontic services are
based on the complexity
and time
involved in moving the teeth.
Limitations
- No benefits are available if orthodontic
treatment began prior to membership in American Dental Plan.
- Additional fees may be charged by the doctor for:
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a. Surgical procedures and/or extraction
cases. b. Care required in excess of 24
months c. Ceramic or Gold Appliances
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d. Broken metal bands. e.
Complications occurring during treatment..
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- If the membership expires before
completion of treatment, member is responsible to pay total usual
and customary charges.
- Choice of Orthodontists is limited to list
of participating Orthodontists.
- No benefits qualify for any work done outside the doctor's
office.
Additional Charges
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Retainers, (standard/removeable) Missed
appointments All other services |
$ 130 ask receptionist 20% discount
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