|
Procedure |
Patient
Co-payment
(OUT OF POCKET) |
|
Diagnostic & Preventive Service
|
|
Oral exam |
No charge |
|
Full mouth x -rays |
No charge |
|
Single films |
No charge |
|
Bitewing series |
No charge |
|
Oral hygiene instruction |
No charge |
|
Cleaning of teeth (polish) |
No charge |
|
Fluoride treatment |
No charge |
|
Emergency treatment |
No charge |
|
Restorative Dentistry Primary & Permanent |
|
Silver amalgam, one surface
(filing) |
$20 |
|
Silver amalgam, two surfaces
(filing) |
$35 |
|
Silver amalgam, three surfaces or
more (filing) |
$50 |
|
Composite filing, one surface |
$25 |
|
Composite filing, two surfaces |
$40 |
|
Composite filing, three surfaces or
more |
$55 |
|
Oral Surgery |
|
Routine extractions - per tooth |
$45 |
|
Surgical extraction |
$75 |
|
Soft tissue impaction |
$95 |
|
Partial bony impaction |
$125 |
|
Full bony impaction |
$160 |
|
Alveolectomy, per quad |
$95 |
|
*Root Canal Therapy |
|
Pulp caping |
$10 |
|
Pulpotomy |
$25 |
|
Root canal therapy - anterior |
$225 |
|
Root canal therapy - bicuspid |
$290 |
|
Root canal therapy - molar |
$395 |
|
Apiectomy |
$195 |
|
*Peridontics |
|
Scaling of teeth - per quad |
$25 |
|
Gingivectomy - per quad |
$125 |
|
Osseous Surgery - Per quad |
$425 |
|
Prosthetics -
Crowns |
|
Acrylic with metal crown |
$295 |
|
Porcelain crown |
$385 |
|
Porcelain with metal crown |
$425 |
|
Stainless steel crown |
$95 |
|
Cast post |
$95 |
|
Recementation per crown |
$35 |
|
Prosthetics - Fixed bridges |
|
Acrylic with metal bridge crown or
pontic |
$295 |
|
Porcelain with metal bridge crown
or pontic |
$425 |
|
Recementation - bridge |
$35 |
|
Prosthetics - Removable |
|
Full upper denture, including
adjustments |
$395 |
|
Full lower denture, including
adjustments |
$395 |
|
Partial upper denture, cast base
and acrylic |
$395 |
|
Partial lower denture, cast base
and acrylic |
$395 |
|
Denture adjustments (for denture
not made in office) |
$35 |
|
Prosthetics - Repairs |
|
Broken body of denture (no teeth
involved) |
$95 |
|
Replacing broken or missing teeth |
$35 |
|
Office reline |
$95 |
|
Lab reline |
$150 |
|
Orthodontics (braces) |
|
Maximum case is 24 months for
orthodontia (braces) |
75% of the UCR (usual & customary
rate) |
|
Limitations
and exclusions
|
|
|
*When
a participating specialist renders these services, the
co-payment
will be 25% less than specialist's usual fees.
CLICK HERE FOR A QUOTE
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