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

1. No benefits are available if orthodontic treatment began prior to membership in American Dental Plan.
2. Additional fees may be charged by the doctor for:

   a. Surgical procedures and/or extraction cases. b. Care required in excess of 24 months c. Ceramic or Gold Appliances

   d. Broken metal bands. e. Complications occurring during treatment..

3. If the membership expires before completion of treatment, member is responsible to pay total usual and customary charges.
4. Choice of Orthodontists is limited to list of participating Orthodontists.
5. No benefits qualify for any work done outside the doctor's office.

Additional Charges

Retainers, (standard/removeable) Missed appointments All other services $ 130 ask receptionist 20% discount