COVERED BENEFITS AND COPAYS

I. PREVENTIVE SERVICESPREVENTIVE SERVICES

• Oral examination

  No Charge

• Intraoral x-rays, complete series

  No Charge

• Bitewing x-rays, single film

  No Charge

• Topical fluoride (child)

  No Charge

• Oral hygiene instruction

  No Charge

• Prophylaxis (teeth cleaning)

  No Charge

• Sealant per tooth

  $25.00

II. ROUTINE SERVICES

• Amalgam, 1 surface

  $85.00

• Amalgam, 2 surfaces

  $95.00

• Amalgam, 3 surfaces

  $105.00

• Amalgam, 4 or more surfaces

  $120.00

• Composite 1 surface anterior

  $125.00

• Composite 2 surfaces anterior

  $145.00

• Composite 3 surfaces anterior

  $175.00

• Composite 4 or more surfaces anterior

  $215.00

• Composite 1 surface posterior

  $140.00

• Composite 2 surfaces anterior

  $165.00

• Composite 3 surfaces anterior

  $190.00

• Composite 4 or more surfaces anterior

  215.00

• Amalgam, 1 surface

  $85.00

• Amalgam, 2 surfaces

  $95.00

• Amalgam, 3 surfaces

  $105.00

• Amalgam, 4 or more surfaces

  $120.00

• Composite 1 surface anterior

  $125.00

• Composite 2 surfaces anterior

  $145.00

• Composite 3 surfaces anterior

  $175.00

• Composite 4 or more surfaces anterior

  $215.00

• Composite 1 surface posterior

  $140.00

• Composite 2 surfaces anterior

  $165.00

• Composite 3 surfaces anterior

  $190.00

• Composite 4 or more surfaces anterior

  215.00

• Extraction, single permanent tooth

  $120.00

• Surgical removal of erupted tooth

  $190.00

• Removal of impacted tooth, soft tissue

  $220.00

• Removal of impacted tooth, partially bony

  $245.00

• Removal of impacted tooth, full bony

  $325.00

• Surgical removal of residual root tips

  $150.00

• Synthetic bone graft

  TBD

• Pulp cap

  $50.00

• Pulpotomy vital or therapeutic

  $85.00

• Root canal, anterior

  $525.00

• Root canal, bicuspid

  $615.00

• Root canal, molar

  $754.00

• Scaling & root planning, per quadrant

  $95.00

• Full Mouth Debridement

  $99.00

• Periodontal Maintenance

  $89.00

• Periodontal Irrigation, per quadrant

  TBD

• Periodontal Irrigation, generalized

  TBD

• Arestin (per site)

  TBD

III. MAJOR SERVICES

• Porcelain fused to base metal crown

  $697.00

• Porcelain fused to noble metal crown

  $747.00

• Porcelain fused to high noble metal

  $747.00

• All porcelain crown

  $747.00

• Porcelain Inlay or Onlay (1-4 surfaces)

  $697.00

• Bridge abutment or pontic unit

  $797.00

• Cast post & core

  $195.00

• Prefabricated post & core *

  $225.00

• *member is responsible for copayment plus actual lab cost of gold

• Reattach crown

  $80.00

• Reattach bridge

  $135.00

• Complete upper or lower denture

  $975.00

• Upper or lower partial denture, resin base

  $775.00

• Upper or lower partial denture, cast metal base with resin saddles

  $1,075.00

• Adjust complete or partial upper or lower denture

  $70.00

• Replace missing or broken teeth, complete denture, each tooth

  $145.00

• Reline complete or partial upper or lower denture, chairside

  $225.00

• Reline complete or partial upper or lower denture, laboratory

  $275.00

• Stayplate

  $475.00

• Add clasp to existing denture

  $200.00

• Denture rebase

  $300.00

IV. ORTHODONTICS

• Full-banded, upper and lower, to age 19

  $2,850.00

• Full-banded, upper and lower, adults

  $3,050.00

• Upper or lower, to age 19

  $1,970.00

• Upper or lower, adult

  $2,120.00

• Ortho Retention upper and lower

  $650.00

• Invisalign

  TBD

V. COSMETIC SERVICES

• In Office Bleaching, full mouth

  $249.00

• Ceramic Crown, 3rd generation

  $747.00

• Labial veneer (porcelain laminate), laboratory

  $847.00

• Night guards, soft, includes lab fee

  $447.00

• Broken Appointment w/out 24 hr notice

  $447.00

• Emergency after-hours

  $145.00