Use this fee schedule if ASP appears in the PLAN
column on the provider list.
**Note -
Colorado & Georgia do NOT follow this fee schedule. Customers in CO
& GA must contact their local ASP office.**
**For Colorado please call 1-800-720-5055 - For Georgia please call
1-770-452-9610**
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ASP Fee Schedule for General Dentists |
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Prices
effective June 1, 2007 |
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Procedure |
Member Pays |
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Oral Exam |
} |
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Office Visit |
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Bitewing X-ray |
$27.50
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Fluoride Treatment - Child
(1/year) |
Total
Charge |
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Home Care Prevention |
(Once
per Year) |
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Cleaning, Child or Adult |
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Pulp Vitality Tests |
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Infection Control |
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(Dental office may require full mouth X-rays on initial visit of
new patients. Usual cost $80.00, Members Cost $35.00) |
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Diagnostic and
Preventative Services |
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Infection
Control |
$10.00
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0120 |
Periodic Oral Evaluation |
$14.00
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0150 |
Comprehensive Oral Evaluation |
$17.00
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0210 |
X-rays - Intraoral - Complete
Series (Including Bitewings) |
$40.00
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0220 |
X-rays - Intraoral - Periapical - 1st Film |
$8.00
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0230 |
X-rays - Intraoral - Periapical - Each Additional Film |
$5.00
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0270 |
Bitewing X-ray - Single Film |
$9.00
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0272 |
Bitewing X-ray - Two Films |
$11.00
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0274 |
Bitewing X-ray - Four Films |
$18.00
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0330 |
Panoramic Film |
$37.00
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1110 |
Prophylaxis - Adult Cleaning |
$36.00
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1120 |
Prophylaxis - Child Cleaning |
$26.00
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1203-1204 |
Fluoride Treatment |
$13.00
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1351 |
Sealant - per tooth |
$17.00
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Restorative |
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Amalgam Fillings |
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2140 |
Primary / Permanent |
1 Surface |
$46.00
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2150 |
2 Surfaces |
$62.00
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2160 |
3 Surfaces |
$76.00
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2161 |
4 or More Surfaces |
$95.00
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Resin-Based Composite |
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2330 |
Anterior |
1 Surface |
$47.00
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2331 |
2 Surfaces |
$67.00
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2332 |
3 Surfaces |
$90.00
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2335 |
4 or More Surfaces |
$119.00
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2391 |
Posterior |
1 Surface |
$62.00
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2392 |
2 Surfaces |
$88.00
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2393 |
3 Surfaces |
$124.00
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2394 |
4 or More Surfaces |
$140.00
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Crowns |
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2750 |
Porcelain Fused to High Noble
Metal |
$470.00
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2751 |
Porcelain Fused to Predominantly
Base Metal |
$420.00
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2752 |
Porcelain Fused to Noble Metal |
$430.00
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2790 |
Full Cast High Noble Metal |
$435.00
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2791 |
Full Cast Predominantly Base Metal |
$410.00
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2930 |
Prefabricated Stainless Steel
Crown - Primary |
$87.00
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2931 |
Prefabricated Stainless Steel
Crown - Permanent |
$98.00
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2950 |
Core Buildup - Including any Pins |
$110.00
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2951 |
Pin Retention per Tooth in
Addition to Restoration |
$20.00
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2952 |
Cast Post and Core in Addition to
Crown |
$137.00
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2954 |
Prefabricated Post and Core in
Addition to Crown |
$110.00
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Periodontics: (Gum Disease) |
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4211 |
Gingivectomy (per quad) |
$175.00
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4341 |
Periodontal Scaling & Root Planing (per quad) |
$100.00
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4355 |
Full Mouth Debridement |
$89.00
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4910 |
Periodontal Maintenance |
$45.00
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(Following Active Treatment) |
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Endodontics: (Root Canals) |
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(EXCLUDING FINAL RESTORATION) |
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3110 |
Pulp Cap Direct |
$20.00
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3120 |
Pulp Cap Indirect |
$20.00
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3220 |
Therapeutic Pulpotomy |
$45.00
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3310 |
Root Canal - Anterior |
$270.00
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3320 |
Root Canal - Bicuspid |
$310.00
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3330 |
Root Canal - Molar |
$390.00
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Prosthetics:
(Dentures & Partials) |
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5110 |
Complete Denture - Maxillary |
$440.00
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5120 |
Complete Denture - Mandibular |
$440.00
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5130 |
Immediate Denture - Maxillary |
$480.00
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5140 |
Immediate Denture - Mandibular |
$480.00
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5213-14 |
Cast Metal Framework w/Resin
Denture Bases |
$565.00
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(Including any conventional
Clasps, Rests or Teeth |
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5410-11 |
5410-11
Adjust Complete Denture |
$28.00
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5520 |
5520
Replace missing or broken tooth |
$45.00
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5650 |
5650 Add
Tooth to Existing Partial Denture |
$48.00
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5660 |
5660 Add
Clasp to Existing Partial Denture |
$62.00
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5730-41 |
5730-41
Reline Complete or Partial Denture (Chairside) |
$120.00
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5750-61 |
5750-61
Reline Complete or Partial Denture (Laboratory) |
$170.00
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Oral Surgery |
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7140 |
Single Tooth Extraction |
$50.00
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(Erupted Tooth or Exposed Root) |
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Orthodontics:
(Braces) |
$3,000.00 |
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(X-rays, study models, tracing,
records and extractions are not included) |
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*All of the above charges are
reduced fees for services performed by a participating GENERAL DENTIST.
*Procedures not listed on this
schedule will be discounted at 20% of the General Dentists normal fee.
Payment is required at the time
of service.
*Fees do not include lab costs.
Lab fees are to be paid directly to the dental office by the member.
**Fees subject to change
periodically without notification.
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***** SPECIALISTS ***** Any treatment provided by a participating SPECIALIST if available, in Oral Surgery, Orthodontists, Periodontics, Pedodontics, or Endodontics will be charged at a 20-25% reduction of the Specialists fees for that particular case.
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