| |
Member Services |
Member Co-Payment |
Diagnostic & Preventative |
Office Visit |
$0.00 |
Oral Exam |
$10.00 |
Fluoride (to age 14) |
$0.00 |
Prophylaxis (cleaning -- adult & child) |
$25.00 |
Single Periodical x-ray |
$10.00 |
Each additional Periodical |
$8.00 |
Bitewing x-ray (1, 2, & 4 films) |
$15.00 |
Intraoral x-ray (incl. Bitewings) |
$52.00 |
Panoramic x-ray |
$40.00 |
Sealant (per tooth) |
$15.00 |
Restorative Dentistry (Filling-Cavities) |
Amalgam Restorations - Primary |
One Surface |
$40.00 |
Two Surfaces |
$50.00 |
Three Surfaces |
$60.00 |
Four Surfaces |
$70.00 |
Amalgam Restorations - Permanent |
One Surface |
$45.00 |
Two Surfaces |
$55.00 |
Three Surfaces |
$65.00 |
Four Surfaces |
$80.00 |
Composite Restorations - Anterior |
One Surface |
$55.00 |
Two Surfaces |
$70.00 |
Three Surfaces |
$85.00 |
Four Surfaces |
$100.00 |
Composite Restorations - Posterior |
One Surface |
$60.00 |
Two Surfaces |
$85.00 |
Three Surfaces |
$105.00 |
Crown and Bridges |
Porcelain Crown/Porcelain with Metal Crown |
$455.00 |
Stainless Steel Crown (permanent or primary) |
$95.00 |
Full Crown |
$435.00 |
Acrylic with Metal Crown |
$425.00 |
Cast Pontic |
$405.00 |
Porcelain with Metal Pontic |
$395.00 |
Acrylic Pontic |
$390.00 |
Recement Crown |
$35.00 |
Crown Buildup (including pins) |
$90.00 |
Crown Post & Core |
$140.00 |
Periodontics** |
Gingivectomy or Gingiovplasty per Quad |
$205.00 |
Gingival Curettage per Quad |
$75.00 |
Gingival Flap Procedure (including root planning) |
$240.00 |
Osseious Surgery per Quad (incl. flap entry and closure) |
$390.00 |
Periodontal Scaling and Root Planning per Quad |
$95.00 |
Full Mouth Debridement |
$65.00 |
Periodontal Maintenance Following Active Therapy |
$60.00 |
Oral Surgery** |
Extraction (Simple) |
$50.00 |
Extraction (Surgical) |
$85.00 |
Soft Tissue Impaction |
$105.00 |
Partial Bony Impaction |
$140.00 |
Full Bony Impaction |
$205.00 |
Root Removal (Exposed Roots) |
$60.00 |
Surgical Exposure of Impacted Tooth |
$195.00 |
Endodontics (Root Canal Therapy)** |
Pulp Capping (Direct/Indirect) |
$25.00 |
Therapeutic Pulpotomy |
$60.00 |
Root Canal Anterior |
$260.00 |
Root Canal Bicuspid |
$315.00 |
Root Canal Molar |
$405.00 |
Prosthetics (Dentures) |
Complete Upper/Lower Denture |
$525.00 |
Immediate Upper/Lower Denture |
$570.00 |
Partial Resin Upper/Lower |
$470.00 |
Partial Cast Metal Base Upper/Lower |
$575.00 |
Removable Unilateral Partial Denture |
$340.00 |
Denture Adjustment |
$30.00 |
Repair Broken Complete Denture Base |
$60.00 |
Replace Missing or Broken Teeth |
$50.00 |
Add Tooth to Existing Partial Denture |
$75.00 |
Add Clasp to Existing Partial Denture |
$90.00 |
Rebase |
$215.00 |
Reline Dentrue (Chairside) |
$120.00 |
Reline Denture (Lab) |
$160.00 |
Tissue Reconditioning per Denture |
$50.00 |
Other Services |
Emergency Palliative Treatment |
$35.00 |
Local Anesthetic |
$10.00 |
Analgesia/Nitrous Oxide |
$20.00 |
Office Visit (After Regular Hours) |
$45.00 |
Missed/Cancelled Appt. (without 24 hr notice) |
$30.00 |
Orthodontics (Braces) |
Comprehensive Orthodontic Treatment (24 months) |
|
Under age 19 |
$2,300.00 |
Age 19 & Over |
$2,500.00 |
Screening Exam |
No Charge |
Initial Workup & x-rays |
$200.00 |
Final Workup & x-rays |
$200.00 |
Lost or Broken Metal Bands |
$10.00 |
Interceptive Per-Ortho Guidance (per Visit) |
$15.00 |
Lost or Broken Head Gear |
$25.00 |
Lost or Irreparable Retainer |
$75.00 |
Partial Treatment/Functional Ortho Treatment |
25% discount |
