| Orthodontic Schedule |
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| Orthodontic service are covered under the Administrators for Dental and Medical Services (ADMS) Dental Plan and are available to all ADMS Members through ADMS affiliated orthodontists, or ADMS dentists who offer orthodontic services in their dental office. A roster of ADMS orthodontists and ADMS Dentists who offer orthodontic services is found in the ADMS "List of Provider Dentists" under "Specialists." A referral from a Member's Primary Dentist is not required. |
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| ORTHODONTIC SERVICES |
COST TO MEMBER |
| Consultation and Diagnosis, Records
Photographs, Cephalometric X-rays,
Models, Panoramic X-ray, or FMX
With Ongoing Orthodontic Services
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$150.00 |
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| Cephalometric X-rays and Diagnostic Out Tracing of Cephalometric X-rays |
Referred |
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| Consultation and Diagnosis - No Ongoing Orthodontic Treatment |
$70.00 |
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| Full Mouth Treatment, Class I and Class II |
| Malocclusion, for up to 24 months of Active Treatment |
| - For Members who begin treatment at age 18 or younger |
$2,500.00
(Down Payment $500) |
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| - For Members who begin treatment at age 19 or older |
$2,900.00
(Down Payment $500) |
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| Half Case Treatment, Class I and Class II |
| Malocclusion, for up to 24 months of Active Treatment |
| - For Members who begin treatment at age 18 or younger |
$1,400.00
(Down Payment $375) |
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| - For Members who begin treatment at age 19 or older |
$1,550.00
(Down Payment $400) |
| Post - Treatment Retainer (Removable) (each) |
$175.00 |
| Treatment Visit (per visit) (After 24 months of Active Treatment) |
$50.00 |
| Adjusting Retainers |
$15.00 |
| Reattach Brackets and Bands (Up to 3 Months) |
$30.00 |
| Reattach Brackets and Bands (After to 3 Months) |
$40.00 |
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| Fixed Appliance |
$500.00 |
| Appliance Removable |
$450.00 |
| Replace Broken Ligature Wires |
$20.00 |
| 1st and 2nd Occurrence |
$25.00 |
| 3rd or More Occurrence |
$45.00 |
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| * INVISALIGN BRACES - Less 25% of usual customary fee. |
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| OTHER SERVICES |
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| 09110 |
Emergency Palliative Treatment |
$30 |
| 09310 |
Consultation |
$15 |
| 01012 |
Infection Control |
$10 |
| 09430 |
Office Visit for Observation |
$15 |
| 09490 |
Broken Appointment Without 24 Hr. Notice |
$25 |
| 09440 |
Office Visit (After Hours) |
$50 |
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Limitations:
1. This Schedule is subject to all portions of the Contract, unless otherwise specified herein.
2. Active orthodontic treatment shall be covered for no more than 24 consecutive months and retention treatment is limited to 18 months.
Any ongoing treatment past 24 months is subject to the Treatment Visit charges.
3. The following services are not a component of this schedule. They are, however, covered at 25% discount off the dentist's usual and customary fees:
a. Replacement of appliances due to theft, loss or breakage,
b. Re-treatment of orthodontic cases;
c. Treatment in progress at inception of eligibility;
d. Changes in treatment necessitated by an accident;
e. Orthodontic treatment that involves:
1. Maxillofacial surgery;
2. Treatment involving surgically exposing impacted teeth (i.e., axillary cuspids);
3. Myofunctional therapy;
4. Cleft palate;
5. Micrognathia;
6. Macroglossia;
7. Hormonal ambulances causing growth and developmental abnormalities;
8. Treatment related to temporomandibular joint disturbances;
9. Mucogingival surgery - severing frenum attachments.
Note: This Orthodontic Schedule is not intended to represent all of the
available orthodontic procedures. For those services not listed on
the ADMS Orthodontic Schedule, the Dentist may charge his/her
Usual and Customary fee, less 25%.
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