Dental Fee Schedule for Members |
Effective: Feb 1st 2023 |
Preventive Services | Member Pays |
Oral exam & diagnosis (one per year) | No Charge* |
Bitewings/Pariapical x-rays (set of 4) available once each membership year | No Charge |
Each additional film | 10 |
Periodic Exams | 38 |
Limited Exams | 52 |
Panoramic x-rays | 89 |
Full Series (non-pano) | 99 |
Routine Cleanings** (Adult) | 77 |
Routine Cleanings** (Child under 14) | 63 |
Difficult Cleanings (heavier scaling)** | 108 |
Emergency treatment palliative, per visit | 82 |
Topical Fluoride (separate or added to cleaning) | 41 |
Sealants (per tooth, includes etch) | 38 |
Materials/Sterilization fee(per patient, per visit) | 12 |
Extractions | |
Simple local anesthetic, (non-surgical) | 110 |
Complex and/or heavily decayed | 125 |
Root Tip Simple | 105 |
Soft Tissue Impaction | 239 |
Restorative Dentistry | |
Amalgam primary/permanent (includes base): | |
Cavities involving one tooth surface | 107 |
Cavities involving two tooth surfaces | 135 |
Cavities involving three tooth surfaces | 182 |
Composite primary/permanent (includes base): | |
One surface (anterior) | 133 |
Two surfaces (anterior) | 157 |
Three surfaces (anterior) | 178 |
Composite Restorations: permanent only (includes etch): | |
One surface filling (posterior) | 149 |
Two surface filling (posterior) | 179 |
Pin retention per tooth | 44 |
Crown and Bridge (per unit) | |
(Includes prep, temporary, lab fees and adjustments) | |
Porcelain w/semi-precious | 889 |
Porcelain w/high noble | 998 |
Full Crown (non-precious) | 788 |
Stainless Steel (Primary or Permanent) | 236 |
Crown build-up w/pin | 216 |
Recement Crown | 72 |
Bridges (per Unit) | |
Porcelain w/semi-precious metal | 889 |
Porcelain w/high noble | 998 |
Recementation (per unit) | 77 |
Periodontics | |
Perio Hygiene Instruction | No Charge |
Re-evaluation (post treatment) | No Charge |
Crown Lengthening | 627 |
Perio Charting* | 84 |
Perio Cleaning (following therapy) | 129 |
Full Mouth Debridement | 233 |
Curettage, scaling or planing (per quadrant) | 192 |
Gingivectomy per quadrant (includes post surgical visits) | 457 |
Osseous or muco-gingival surgery (per quadrant, includes post surgical visits) | 648 |
Gingivectomy (per tooth) | 148 |
Endodontics | |
Pulp capping | 76 |
Pulpotomy | 177 |
Anterior root canal therapy | 528 |
Bicuspid root canal therapy | 689 |
Molar root canal therapy | 849 |
Apicoectomy (separate procedure, excludes molars) | 487 |
Prosthetics | |
Resin/Acrylic Partial w/cast clasps | 1099 |
Cast Partial, resin saddles (6 teeth, 2 clasps) (additional teeth $25 each, additional saddles $60 each) |
1290 |
Stayplate/Flipper(u/l up to 2 teeth, office only) | 497 |
High quality upper/lower denture (each) | 1245 |
Immediate Denture (will need to be relined) | 1310 |
Denture adjustments | 68 |
Reline, denture or partial (office) | 219 |
Reline, denture or partial (laboratory) | 328 |
Broken denture repair (no teeth involved) | 118 |
Replace tooth (includes lab fee) | 127 |
All materials used are ADA approved. |
Special Notes: |
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