Dental Fee Schedule

Any treatment performed by a participating advanced degree specialist in Endodontics, Pedodontics, Periodontics, Orthodontics, Prosthodontics and Oral Surgery will be charged at a 25% reduction off participating specialist standard fees.  
All General Dentistry not listed on fee schedule will be charged at a 30% Discount. Discuss all fees with dentist prior to any treatment.
For all treatments, Lab Cost may be charged in addition to scheduled fees.

DIAGNOSTIC AND PREVENTATIVE




 
Non-member
Average Fee
Member’s Fees
Office Visit $75.00 3
Emergency Office Visit 90 10
Infection Control 30% OFF
X-Ray, Intraoral Periapical, each 10 1
X-Ray, Bitewings, each 10 1
X-Ray, Panoramic Film 125 20
X-Ray, Complete Series, Full Mouth 150 25
Routine Cleaning (incl. polishing & routine scaling) 95 21
Sealant, per tooth 65 17
Comprehensive   Oral Evaluation
95
20

FILLINGS, CROWNS, AND BRIDGES

 
Silver Filling (Amalgam) primary or permanent  
  1 Surface 105 28
2 Surfaces 155 34
3 Surfaces 185 48
4 Surfaces 225 65
Tooth-Colored Fillings (Resin-based Composite) Anterior, Posterior, or involving Incisal Angle
  1 Surface 150 46
2 Surfaces 210 56
3 Surfaces 260 90
4 Surfaces 310 100
Porcelain Crown fused to:  
Non-precious or predominately base metal. 950 353
Noble or High Noble metal 1200 415
Full crown cast noble or High Noble metal 1200 383
Full crown cast nonprecious metal. 1200 310
Core Buildup, including any pins 230 90
Prefab Crown, Provisional or permanent 225 90
Fixed Bridge (Crown/Pontic Priced Per Unit)
     

ENDODONTICS (Root Canals, etc)

Pulp Cap – Direct 75 18
Pulp Cap – Indirect 75 18
Root Canal (excluding final restoration)    
Anterior 600 185
Bicuspid 750 235
Molar 900 305
 

TOOTH REMOVAL/EXTRACTIONS (Performed by General Dentist)

Single Tooth, simple extraction, erupted tooth or exposed root 125 35
Impacted Tooth – Soft tissue 225 78
Impacted Tooth – Partially bony 275 85
Impacted Tooth – Completely bony 350 95
Surgical Removal resid. Roots 225 80

PROSTHODONTICS (Dentures, Partials, etc.)

Upper Full Denture   1400 390
Lower Full Denture     1400 390
Immediate Denture 1200 370
Upper partial 1400 390
Lower partial 1400 390
Flexible Partial or Complete   30% OFF
Repair broken complete denture base 115 45
Replace missing/broken teeth – complete denture (each tooth) 110 40
Lab Cost will be extra
 

PERIODONTICS (Performed by a General Dentist)

Consultation 75 10
Periodontal Scaling and Root Planing 4+ teeth Per Quadrant 195 65
Gingival Curettage 4+ Per Quadrant 225 65
Gingivectomy or Gingivoplasty Per Quad 450 200
 

ORTHODONTICS

Conventional Braces 25% OFF
Cosmetic Braces 25% OFF
Any Orthodontic Treatment 25% OFF
Any treatment performed by a participating advanced degree specialist in Endodontics, Pedodontics, Periodontics, Orthodontics, Prosthodontics and Oral Surgery will be charged at a 25% reduction off participating specialist standard fees.
All General Dentistry not listed on fee schedule will be charged at a 30% Discount. Discuss all fees with dentist prior to any treatment.
For all treatments, Lab Cost may be charged in addition to scheduled fees.

 


 

 

 


DISCLOSURE: This plan is NOT insurance. The plan provides discounts at certain health care providers for medical services. The plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount plan organization.
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