2024 FEE SCHEDULE | Coast Dental

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 ofce 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., (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

reserved. CD-103036 R02/24

2024 FEE SCHEDULE

page 1 of 12

Membership Program

Diagnostic Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D0120 Periodic oral exam $59 $0 100%

D0140 Limited oral exam, problem-focused or emergency exam $87 $25 71%

D0150 Comprehensive oral evaluation, new or established patient $102 $0 100%

D0160 Detailed and extensive evaluation $178 $90 49%

D0170 Re-evaluation limited, problem-focused exam $86 $40 53%

D0180 Comprehensive periodontal exam $114 $55 52%

D0191 Assessment of patient $92 $15 84%

D0210 Intraoral x-rays, complete series including bitewings, 1x every 3 years $155 $0 100%

D0220 Intraoral x-ray, periapical, rst lm $35 $19 46%

D0230 Intraoral x-ray, periapical, each additional lm $30 $17 43%

D0240 Intraoral x-ray, occlusal lm $48 $18 63%

D0250 Extraoral x-ray, rst lm $76 $24 68%

D0260 Extraoral x-ray, each additional lm $66 $22 67%

D0270 Bitewing x-ray, single lm $35 $18 49%

D0272 Bitewing x-rays, two lms $54 $20 63%

D0273 Bitewing x-rays, three lms $64 $32 50%

D0274 Bitewing x-rays, four lms $77 $38 51%

D0277 Vertical bitewing x-rays, 7 to 8 lms $116 $45 61%

D0290 Posterior/Anterior or lateral skull and facial x-ray lm $152 $80 47%

D0330 Panoramic x-ray lm $131 $45 66%

D0350 Oral/Facial photographic images $83 $41 51%

D0416 Viral culture $187 $89 52%

D0421 Genetic test for susceptibility to oral diseases $146 $74 49%

D0425 Caries susceptibility test $99 $68 31%

D0460 Pulp vitality test $66 $37 44%

D0470 Diagnostic cast $138 $68 51%

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 ofce 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., (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

reserved. CD-103036 R02/24

2024 FEE SCHEDULE

page 2 of 12

Membership Program

Preventive Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D1110 Adult cleaning, above the gum line (Two free per year with SmilePlus Silver) $107 $107 0%

D1120 Child cleaning, above the gum line (Or two free per year with SmilePlus Silver) $83 $83 0%

D1206 Topical application of uoride (One free per year with SmilePlus Gold) $54 $54 0%

D1351 Sealant, per tooth $69 $26 62%

D1510 Space maintainer, xed, unilateral $361 $210 42%

D1515 Space maintainer, xed, bilateral $478 $315 34%

D1550 Recementation of space maintainer $99 $58 41%

D1555 Removal of space maintainer $97 $58 40%

Restorative Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D2330 Resin/Composite lling, one surface, anterior $197 $83 58%

D2331 Resin/Composite lling, two surfaces, anterior $239 $142 41%

D2332 Resin/Composite lling, three surfaces, anterior $294 $194 34%

D2335 Resin/Composite lling, four + surfaces, anterior $367 $236 36%

D2390 Resin/Composite crown, anterior $543 $341 37%

D2391 Resin/Composite lling, one surface, posterior $212 $131 38%

D2392 Resin/Composite lling, two surfaces, posterior $271 $179 34%

D2393 Resin/Composite lling, three surfaces, posterior $333 $226 32%

D2394 Resin/Composite lling, four + surfaces, posterior $398 $263 34%

D2510 Inlay, metallic, one surface $1,060 $578 45%

D2520 Inlay, metallic, two surfaces $1,116 $630 44%

D2530 Inlay, metallic, three surfaces $1,165 $709 39%

D2542 Onlay, metallic, two surfaces $1,177 $735 38%

D2543 Onlay, metallic, three surfaces $1,220 $788 35%

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 ofce 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., (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

reserved. CD-103036 R02/24

2024 FEE SCHEDULE

page 3 of 12

Membership Program

Restorative Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D2544 Onlay, metallic, four + surfaces $1,263 $814 36%

D2610 Inlay, porcelain/ceramic, one surface $1,123 $551 51%

D2620 Inlay, porcelain/ceramic, two surfaces $1,145 $578 50%

D2630 Inlay, porcelain/ceramic, three surfaces $1,216 $604 50%

D2642 Onlay, porcelain/ceramic, two surfaces $1,205 $735 39%

D2643 Onlay, porcelain/ceramic, three surfaces $1,234 $761 38%

D2644 Onlay, porcelain/ceramic, four + surfaces $1,284 $814 37%

D2740 Crown, porcelain/ceramic, Zirconia $1,454 $799 45%

D2750 Crown, porcelain fused to high noble metal $1,319 $785 40%

D2751 Crown, porcelain fused to predominantly base metal $1,127 $578 49%

D2752 Crown, porcelain fused to noble metal $1,174 $630 46%

D2780 Crown, 3/4 cast high noble metal $1,284 $788 39%

D2783 Crown, 3/4 porcelain/ceramic $1,284 $814 37%

D2790 Crown, full cast high noble metal $1,269 $814 36%

D2791 Crown, full cast predominantly base metal $1,113 $551 50%

D2792 Crown, full cast noble metal $1,170 $656 44%

D2794 Crown, titanium $1,291 $814 37%

D2799 Provisional crown $519 $210 60%

D2910 Recement inlays/onlays $136 $79 42%

D2915 Recement cast or prefabricated post & core $138 $79 43%

D2920 Recement crowns $133 $79 41%

D2930 Prefabricated stainless steel crown, primary $311 $184 41%

D2931 Prefabricated stainless steel crown, permanent $359 $236 34%

D2932 Prefabricated resin crown $411 $236 43%

D2950 Core buildup, including any pins $309 $158 49%

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 ofce 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., (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

reserved. CD-103036 R02/24

2024 FEE SCHEDULE

page 4 of 12

Membership Program

Restorative Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D2951 Pin retention, per tooth, in addition to restoration $91 $47 48%

D2952 Post & core, in addition to crown $476 $315 34%

D2954 Prefabricated post & core, in addition to crown $387 $210 46%

D2955 Post removal, not in conjunction with endo therapy $341 $228 33%

D2962 Labial veneer, porcelain laminate, laboratory $1,347 $814 40%

D2971 Crown construction under partial $286 $79 72%

D2980 Crown repair $339 $184 46%

Endodontic Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D3110 Pulp cap, direct, excluding nal restoration $98 $53 46%

D3120 Pulp cap, indirect, excluding nal restoration $98 $53 46%

D3220 Therapeutic pulpotomy, excluding nal restoration $242 $126 48%

D3221 Gross pulpal debridement, primary and permanent teeth $272 $158 42%

D3240 Pulpal therapy, posterior, primary, excluding nal restoration $352 $236 33%

D3310 Anterior root canal, excluding nal restoration $886 $509 43%

D3320 Bicuspid root canal, excluding nal restoration $999 $625 37%

D3330 Molar root canal, excluding nal restoration $1,219 $709 42%

D3331 Treatment of root canal obstructions, non-surgical access $754 $210 72%

D3332 Incomplete endo therapy, unrestorable tooth $523 $318 39%

D3346 Retreatment of root canal, anterior $1,007 $630 37%

D3347 Retreatment of root canal, bicuspid $1,138 $683 40%

D3348 Retreatment of root canal, molar $1,382 $840 39%

D3920 Hemisection, including any root removal $543 $373 31%

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 ofce 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., (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

reserved. CD-103036 R02/24

2024 FEE SCHEDULE

page 5 of 12

Membership Program

Periodontic Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D4210 Gingivectomy or gingivoplasty, 4 + bound teeth per quadrant $736 $473 36%

D4211 Gingivectomy or gingivoplasty, 1 to 3 teeth $385 $168 56%

D4212

Gingivectomy or gingivoplasty to allow access for restorative

procedure, per tooth

$346 $100 71%

D4230 Anatomical crown exposure, 4 + bound teeth per quadrant $985 $368 63%

D4231 Anatomical crown exposure, 1 to 3 teeth $696 $341 51%

D4240 Gingival ap procedure, 4 + bound teeth per quadrant $858 $572 33%

D4241 Gingival ap procedure, including root planing, 1 to 3 teeth $702 $499 29%

D4245 Apically positioned ap $938 $625 33%

D4249 Crown lengthening, hard and soft tissue $902 $525 42%

D4260 Osseous surgery, 4 + teeth per quadrant $1,311 $840 36%

D4261 Osseous surgery, 1 to 3 teeth $1,058 $656 38%

D4263 Bone replacement, rst site $785 $473 40%

D4264 Bone replacement graft, each additional site in quadrant $636 $341 46%

D4266 Guided tissue regeneration, resorbable barrier $889 $630 29%

D4267 Guided tissue regeneration, nonresorbable barrier $1,024 $772 25%

D4268 Surgical revision procedure, per tooth $941 $630 33%

D4270 Pedicle soft tissue graft $988 $630 36%

D4271 Free soft tissue graft $865 $630 27%

D4274 Distal or proximal wedge procedure $773 $536 31%

D4276 Combined connective tissue and double pedicle graft $1,300 $893 31%

D4277 Free soft tissue graft procedure $1,160 $630 46%

D4320 Provisional splinting, intracoronal $607 $368 39%

D4321 Provisional splinting, extracoronal $548 $341 38%

D4341 Periodontal scaling and root planing, 4 + teeth per quadrant $296 $135 54%

D4342 Periodontal scaling and root planing, 1 to 3 teeth $222 $93 58%

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 ofce 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., (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

reserved. CD-103036 R02/24

2024 FEE SCHEDULE

page 6 of 12

Membership Program

Periodontic Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D4355 Full mouth debridement to enable evaluation and diagnosis $210 $104 50%

D4910 Periodontal maintenance (Three free per year with SmilePlus Gold) $159 $159 0%

D4381 Initial Minocycline, localized delivery $151 $121 20%

D4381 Minocycline, additional site, same tooth $20 $20 0%

Removable Prosthodontic Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D5110 Deluxe denture, upper $2,271 $699 69%

D5110 Elite denture, upper $2,271 $799 65%

D5110 Premier denture, upper $999 $899 10%

D5120 Deluxe denture, lower $2,272 $699 69%

D5120 Elite denture, lower $2,272 $799 65%

D5120 Premier denture, lower $999 $899 10%

D5130 Immediate Premier denture, upper $1,099 $999 9%

D5130 Immediate Deluxe denture, upper $2,385 $799 66%

D5130 Immediate Elite denture, upper $2,385 $899 62%

D5140 Immediate Premier denture, lower $1,099 $999 9%

D5140 Immediate Deluxe denture, lower $2,419 $799 67%

D5140 Immediate Elite denture, lower $2,419 $899 63%

D5211 Partial, upper, resin base $899 $650 28%

D5212 Partial, lower, resin base $1,629 $650 60%

D5213 Deluxe partial, upper $2,320 $656 72%

D5214 Deluxe partial, lower $2,320 $656 72%

D5213 Elite partial, upper $2,121 $998 53%

D5214 Elite partial, lower $2,128 $998 53%

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 ofce 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., (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

reserved. CD-103036 R02/24

2024 FEE SCHEDULE

page 7 of 12

Membership Program

Removable Prosthodontic Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D5213 Premier partial, upper $2,121 $1,155 46%

D5214 Premier partial, lower $2,128 $1,155 46%

D5225 Partial denture with exible base, upper $1,827 $866 53%

D5226 Partial denture with exible base, lower $1,820 $866 52%

D5213 Immediate Deluxe partial, upper $2,121 $839 60%

D5214 Immediate Deluxe partial, lower $2,128 $839 61%

D5225 Cosmetic partial, Valplast

, upper $1,851 $1,103 40%

D5226 Cosmetic partial, Valplast

, lower $1,825 $1,103 40%

D5213 Combination partial, upper, metal base and clear clasp $2,121 $1,313 38%

D5214 Combination partial, lower, metal base and clear clasp $2,128 $1,313 38%

D5281 Removable unilateral partial denture, one piece $1,201 $814 32%

D5410 Adjust complete denture, upper $107 $53 50%

D5411 Adjust complete denture, lower $106 $53 50%

D5421 Adjust partial denture, upper $106 $53 50%

D5422 Adjust partial denture, lower $106 $53 50%

D5510 Repair broken complete denture base $259 $142 45%

D5520 Replace missing or broken teeth, complete denture $226 $104 54%

D5610 Repair acrylic saddle or base $245 $142 42%

D5620 Repair cast framework $343 $179 48%

D5630 Repair or replace broken clasp $317 $168 47%

D5640 Replace broken teeth, per tooth $231 $104 55%

D5650 Add tooth to existing partial denture $272 $135 50%

D5660 Add clasp to existing partial denture $319 $188 41%

D5670 Replace all teeth and acrylic on cast metal framework, upper $871 $499 43%

D5671 Replace all teeth and acrylic on cast metal framework, lower $884 $499 44%

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 ofce 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., (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

reserved. CD-103036 R02/24

2024 FEE SCHEDULE

page 8 of 12

Membership Program

Removable Prosthodontic Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D5710 Rebase, complete upper denture $692 $378 45%

D5711 Rebase, complete lower denture $691 $378 45%

D5720 Rebase, upper partial denture $666 $378 43%

D5721 Rebase, lower partial denture $666 $378 43%

D5730 Reline, upper complete denture, chairside $444 $221 50%

D5731 Reline, lower complete denture, chairside $444 $221 50%

D5740 Reline, upper partial denture, chairside $434 $221 49%

D5741 Reline, lower partial denture, chairside $440 $221 50%

D5750 Reline, upper complete denture, laboratory $543 $289 47%

D5751 Reline, lower complete denture, laboratory $558 $289 48%

D5760 Reline, upper partial denture, laboratory $545 $289 47%

D5761 Reline, lower partial denture, laboratory $548 $289 47%

D5810 Denture, temporary, complete upper $1,029 $499 52%

D5811 Denture, temporary, complete lower $1,037 $499 52%

D5820 Interim partial denture (ipper), upper $839 $419 50%

D5821 Interim partial denture (ipper), lower $839 $419 50%

D5850 Tissue conditioning, upper denture $247 $137 45%

D5851 Tissue conditioning, lower denture $247 $137 45%

D5860 Overdenture complete $2,048 $1,260 38%

D5861 Overdenture partial $1,997 $1,260 37%

D5862 Precision attachment $838 $420 50%

D5867 Replacement of semi-precision or precision attachment $469 $105 78%

D5982 Surgical stent $528 $294 44%

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 ofce 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., (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

reserved. CD-103036 R02/24

2024 FEE SCHEDULE

page 9 of 12

Membership Program

Implant Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D6010 Surgical placement of implant body, endosteal implant $2,271 $1,260 45%

D6012 Surgical placement of interim implant $1,955 $1,181 40%

D6050 Surgical placement, transosteal implant $6,297 $4,410 30%

D6053 Implant/abutment supported removable denture, fully edentulous $2,953 $1,155 61%

D6054

Implant/abutment supported removable denture,

partially edentulous

$2,894 $1,260 56%

D6055 Dental implant supported connection bar $3,508 $1,785 49%

D6056 Prefabricated abutment, includes placement $879 $525 40%

D6057 Custom abutment, includes placement $1,037 $709 32%

D6058 Abutment supported porcelain/ceramic crown $1,629 $1,045 36%

D6059 Abutment supported PFM high noble crown $1,654 $998 40%

D6065 Implant supported porcelain/ceramic crown $1,768 $1,103 38%

D6066

Implant supported PFM (titanium, titanium alloy, high noble metal)

crown

$1,728 $1,076 38%

D6069 Abutment supported retainer for PFM to high noble metal FPD $1,659 $1,076 35%

D6070 Abutment supported retainer for PFM base metal FPD $1,580 $998 37%

D6078 Implant/abutment supported xed denture for fully edentulous arch $5,233 $3,150 40%

D6091 Replacement of semi/precision attachment $671 $420 37%

D6092 Recement implant/abutment supported crown $180 $105 42%

D6093 Recement implant/abutment xed partial $214 $105 51%

Fixed Prosthodontic Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D6210 Pontic, cast high noble metal $1,203 $735 39%

D6211 Pontic, cast predominantly base metal $1,126 $551 51%

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 ofce 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., (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

reserved. CD-103036 R02/24

2024 FEE SCHEDULE

page 10 of 12

Membership Program

Fixed Prosthodontic Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D6212 Pontic, cast noble metal $1,137 $656 42%

D6214 Pontic, titanium $1,286 $788 39%

D6240 Pontic, porcelain fused to high noble metal $1,233 $709 42%

D6241 Pontic, porcelain fused to predominantly base metal $1,126 $578 49%

D6242 Pontic, porcelain fused noble metal $1,179 $630 47%

D6245 Pontic, porcelain/ceramic, Zirconia $1,384 $761 45%

D6250 Pontic, resin with high noble metal $1,249 $709 43%

D6251 Pontic, resin with predominantly base metal $1,234 $656 47%

D6252 Pontic, resin with noble metal $1,234 $683 45%

D6545 Cast metal retainer for acid etch bridge $1,036 $478 54%

D6548 Retainer, porcelain/ceramic for resin bonded xed prosthetics $1,154 $656 43%

D6600 Inlay, porcelain/ceramic, 2 surfaces $1,185 $839 29%

D6601 Inlay, porcelain/ceramic, 3 + surfaces $1,195 $893 25%

D6602 Inlay, cast high noble, 2 surfaces $1,149 $814 29%

D6603 Inlay, cast high noble, 3 + surfaces $1,180 $840 29%

D6609 Onlay, porcelain/ceramic, 3 + surfaces $1,278 $940 26%

D6 611 Onlay, cast high noble metal, 3 + surfaces $1,284 $940 27%

D6614 Onlay, cast noble metal, 2 surfaces $1,185 $929 22%

D6615 Onlay, cast noble metal, 3 + surfaces $1,245 $935 25%

D6720 Crown, resin with high noble metal $1,248 $709 43%

D6740 Crown, porcelain/ceramic, Zirconia $1,391 $799 43%

D6750 Crown, porcelain fused to high noble metal $1,234 $734 41%

D6751 Crown, porcelain fused to predominantly base metal $1,14 4 $604 47%

D6752 Crown, porcelain fused to noble metal $1,177 $656 44%

D6790 Crown, full cast high noble metal $1,234 $814 34%

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 ofce 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., (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

reserved. CD-103036 R02/24

2024 FEE SCHEDULE

page 11 of 12

Membership Program

Fixed Prosthodontic Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D6792 Crown, full cast noble metal $1,173 $709 40%

D6793 Provisional retainer crown $670 $210 69%

D6810 Additional charge, per unit for multiple crowns $295 $104 65%

D6920 Connection bar $1,236 $788 36%

D6930 Recement xed partial denture $204 $105 49%

D6950 Precision attachment $763 $441 42%

D6973 Core buildup for retainer, including any pins $288 $200 31%

D6975 Coping, metal $742 $525 29%

D6980 Bridge repair $468 $289 38%

Oral & Maxillofacial Surgery Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D7111 Extraction, coronal remnants, decidous teeth $160 $95 41%

D7140 Extraction, erupted tooth or exposed root $217 $100 54%

D7210 Surgical extraction of erupted tooth requiring elevation $329 $189 43%

D7220 Removal of impacted tooth, soft tissue $369 $210 43%

D7230 Removal of impacted tooth, partially bony $464 $242 48%

D7240 Removal of impacted tooth, completely bony $572 $331 42%

D7241 Removal of impacted tooth, completely bony $671 $394 41%

D7250 Surgical removal of residual tooth roots $360 $210 42%

D7260 Oroantral stula closure $1,410 $551 61%

D7280 Surgical access of erupted tooth $562 $341 39%

D7285 Biopsy of oral tissue (hard) $579 $263 55%

D7286 Biopsy of oral tissue (soft) $400 $163 59%

D7288 Brush biopsy, transepithelial sample collection $247 $105 57%

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 ofce 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., (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

reserved. CD-103036 R02/24

2024 FEE SCHEDULE

page 12 of 12

Membership Program

Adjunctive General Services (Performed by a General Dentist)

ADA

Code Procedure Description

Non-

Member

SmilePlus

Member SAVE

D9110 Palliative (emergency) treatment of dental pain $154 $79 49%

D9120 Fixed partial denture sectioning $272 $152 44%

D9210

Local anesthesia not in conjunction with

operational/surgical procedure

$88 $32 64%

D9211 Regional block anesthesia $107 $79 26%

D9215 Local anesthesia $76 $12 84%

D9220 General anesthesia, rst 30 minutes $400 $236 41%

D9221 General anesthesia, each additional 15 minutes $175 $104 41%

D9230 Inhalation of nitrous oxide, analgesia, anxiolysis $97 $47 52%

D9241 Intravenous sedation/analgesia, rst 30 minutes $420 $257 39%

D9242 Intravenous sedation/analgesia, each additional 15 minutes $165 $104 37%

D9248 Non-intravenous conscious sedation $370 $209 44%

D9440 Emergency ofce visit, after regularly scheduled hours $218 $89 59%

D9910 Application of desensitizing medicaments $74 $21 72%

D9 911 Application of desensitizing resin, per tooth $94 $42 55%

D9940 Occlusal guards, by report, hard $686 $394 43%

D9941 Fabrication of athletic mouthguards $316 $168 47%