Service |
Plan Fee |
Usual Fee |
Savings |
Evaluations |
|
|
|
0120 Exam-Periodic |
$37 |
$67 |
45% |
0140 Exam - Limited |
$53 |
$97 |
45% |
0145 Oral Examination under 3 |
$54 |
$98 |
45% |
0150 Comprehensive Exam |
$58 |
$106 |
45% |
FREE Services/Consultations |
|
|
|
Oral Cancer Screening |
FREE |
|
|
Cosmetic Consultation |
FREE |
|
|
Orthodontic Consultation |
FREE |
|
|
Preventative |
|
|
|
0210 Full Mouth X-Ray |
$111 |
$170 |
35% |
0220-0230 Single X-Ray |
$18 |
$36 |
50% |
0270-0274 Bitewings |
$40 |
$80 |
50% |
0330 Panoramic X-ray |
$77 |
$153 |
50% |
1110 Basic Cleaning – Adult |
$69 |
$115 |
40% |
1110 Basic Cleaning – Teen |
$57 |
$95 |
40% |
1120 Basic Cleaning – Child |
$55 |
$85 |
35% |
1206 Fluoride Treatment |
$22 |
$40 |
45% |
1351 Sealant – Per Tooth |
$36 |
$66 |
45% |
Restorations (Fillings) |
|
|
|
Composite Fillings – Anterior |
|
|
|
2330 1 Surface |
$161 |
$214 |
25% |
12331 2 Surface |
$191 |
$255 |
25% |
2332 3 Surface |
$233 |
$310 |
25% |
2335 4 Surface |
$297 |
$371 |
20% |
Composite Fillings – Posterior |
|
|
|
2391 1 Surface |
$177 |
$236 |
25% |
2392 2 Surface |
$226 |
$301 |
25% |
2393 3 Surface |
$250 |
$385 |
35% |
2394 4 Surface |
$300 |
$462 |
35% |
Inlay/Onlay Restorations |
|
|
|
Porcelain Inlay |
|
|
|
2610 1 Surface |
$1028 |
$1285 |
20% |
2620 2 Surface |
$1063 |
$1329 |
20% |
2630 3+ Surface |
$1133 |
$1416 |
20% |
Porcelain/Ceramic/CEREC Onlay |
|
|
|
2642 2 Surface |
$1142 |
$1344 |
15% |
2643 3 Surface |
$1174 |
$1381 |
15% |
2644 4 + Surface |
$1237 |
$1455 |
15% |
Service |
Plan Fee |
Usual Fee |
Savings |
Crown/Single Restorations |
|
|
|
2740 Crown – Porcelain/Ceramic |
$1020 |
$1275 |
20% |
2740 Crown – CEREC |
$1020 |
$1275 |
20% |
2750 Crown – Porcelain/High Noble |
$1084 |
$1275 |
15% |
2790 Crown – Full Cast High Noble |
$1169 |
$1375 |
15% |
2920 Replacement Perm Crown |
$101 |
$134 |
25% |
2929 Porcelain Crown/Primary Tooth |
$340 |
$425 |
20% |
2930 PreFab Stainless – Primary |
$231 |
$308 |
25% |
2933 Stainless Steel Crown/Resin Window |
$324 |
$405 |
20% |
2950 Core Buildup, Including Pins |
$172 |
$312 |
45% |
2954 PreFab Post & Core-Per Tooth |
$224 |
$407 |
45% |
2962 Porcelain Veneer |
$1148 |
$1435 |
20% |
Implant Restorations |
|
|
|
6052 Precision Attachment |
$495 |
$550 |
10% |
6056 Prefabricated Abutment |
$665 |
$739 |
10% |
6057 Custom Implant Abutment |
$794 |
$882 |
10% |
6059 Abutment Supported PFM |
$1440 |
$1600 |
10% |
6068 Abutment Supp. All Ceramic Ret. Fixed |
$1350 |
$1500 |
10% |
Endodontics |
3220 Therapeutic Pulpotomy |
$214 |
$238 |
10% |
3221 Pulpal Debridement |
$238 |
$264 |
10% |
3310 Root Canal – Anterior |
$793 |
$881 |
10% |
3320 Root Canal – Bicuspid |
$897 |
$997 |
10% |
3330 Root Canal – Molar |
$1098 |
$1220 |
10% |
Periodontics |
|
|
|
4342 Scaling/Root Planing
1-3 Teeth Per Quadrant |
$166 |
$208 |
20% |
4341 Scaling/Root Planing
4 or more Teeth Per Quadrant |
$205 |
$293 |
30% |
4355 Full Mouth Debridement |
$153 |
$204 |
25% |
4910 Periodontal Maintenance |
$133 |
$166 |
20% |
4381 Arestin – Minocycline HCI |
$97 |
$108 |
10% |
Service |
Plan Fee |
Usual Fee |
Savings |
Dentures and Partials |
|
|
|
5110 Complete Denture (Upper) |
$1440 |
$1800 |
20% |
5120 Complete Denture (Lower) |
$1440 |
$1800 |
20% |
5130 Immediate Denture (Upper) |
$1596 |
$1995 |
20% |
5140 Immediate Denture (Lower) |
$1596 |
$1995 |
20% |
5211 Partial Denture Acrylic (Upper) |
$1190 |
$1400 |
15% |
5212 Partial Denture Acrylic (Lower) |
$1190 |
$1400 |
15% |
5213 Partial Denture Metal (Upper) |
$1666 |
$1960 |
15% |
5214 Partial Denture Metal (Lower) |
$1666 |
$1960 |
15% |
5511-5512 Repair Denture - Broken Base |
$248 |
$310 |
20% |
5520 Repair Tooth |
$224 |
$280 |
20% |
5611-5612 Repair Partial Acrylic |
$238 |
$280 |
15% |
5640 Repair Partial Tooth |
$238 |
$280 |
15% |
5850 Tissue Conditioning (Upper) |
$158 |
$225 |
30% |
5851 Tissue Conditioning (Lower) |
$158 |
$225 |
30% |
Adjustments to Dentures |
|
|
|
5650 Add Tooth to Existing Partial |
$238 |
$280 |
15% |
5750-5751 Reline Denture,
In Lab, Per Arch |
$396 |
$565 |
30% |
5760-5761 Reline Partial,
In Lab, Per Arch |
$350 |
$500 |
30% |
5820-5821 Interim Partial Denture,
Per Arch |
$469 |
$586 |
20% |
Fixed Bridge Work |
|
|
|
6210 Maryland Bridge Pontic |
$1113 |
$1309 |
15% |
6240 Porcelain/Metal Pontic |
$1113 |
$1309 |
15% |
6545 Maryland Bridge Abutment |
$709 |
$834 |
15% |
6750 Porcelain/Metal Abutment |
$1123 |
$1321 |
15% |
6930 Recement Fixed Bridge |
$167 |
$196 |
15% |
Extractions |
|
|
|
7111 Primary Tooth Remnant Coronal |
$93 |
$155 |
40% |
7140 Extraction Erupted Tooth |
$137 |
$195 |
30% |
7210 Surgical Removal - Erupted Tooth |
$284 |
$315 |
10% |
Miscellaneous |
|
|
|
1510 Space Maintainer (Unilateral) |
$294 |
$368 |
20% |
1515 Space Maintainer (Bilateral) |
$420 |
$525 |
20% |
9110 Palliative Treatment |
$92 |
$168 |
45% |
9230 Nitrous |
$63 |
$90 |
30% |
9940 Occlusal Guard (Hard/Soft) |
$444 |
$555 |
20% |
Teeth Whitening Procedures |
|
|
|
9972 Whitening Take Home |
$210 |
$350 |
40% |
9972 Whitening In House |
$224 |
$280 |
20% |
|
|
|
|
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