Dental Fee Schedule for Members |
Effective: Jan 1st 2019 |
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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 | 7 |
Addt'l exams ( includes periodic & comprehensive ) | 33 |
Panoramic x-rays | 71 |
Full Series (non-pano) | 95 |
Routine Cleanings** (Adult) | 69 |
Routine Cleanings** (Child under 14) | 58 |
Difficult Cleanings (heavier scaling)** | 97 |
Emergency treatment palliative, per visit | 68 |
Topical Fluoride (separate or added to cleaning) | 38 |
Sealants (per tooth, includes etch) | 36 |
Materials/Sterilization fee(per patient, per visit) | 12 |
Extractions | |
Simple local anesthetic, (non-surgical) | 88 |
Complex and/or heavily decayed | 107 |
Root Tip Simple | 98 |
Soft Tissue Impaction | 215 |
Restorative Dentistry | |
Amalgam primary/permanent (includes base): | |
Cavities involving one tooth surface | 95 |
Cavities involving two tooth surfaces | 127 |
Cavities involving three tooth surfaces | 138 |
Composite primary/permanent (includes base): | |
One surface (anterior) | 114 |
Two surfaces (anterior) | 140 |
Three surfaces (anterior) | 162 |
Composite Restorations: permanent only (includes etch): | |
One surface filling (posterior) | 138 |
Two surface filling (posterior) | 164 |
Pin retention per tooth | 38 |
Crown and Bridge (per unit) | |
(Includes prep, temporary, lab fees and adjustments) | |
Porcelain w/semi-precious | 842 |
Porcelain w/high noble | 896 |
Full Crown (non-precious) | 712 |
Stainless Steel (Primary or Permanent) | 229 |
Crown build-up w/pin | 184 |
Recement Crown | 59 |
Bridges (per Unit) | |
Porcelain w/semi-precious metal | 842 |
Porcelain w/high noble | 896 |
Recementation (per unit) | 59 |
Periodontics | |
Perio Hygiene Instruction | No Charge |
Re-evaluation (post treatment) | No Charge |
Crown Lengthening | 527 |
Perio Charting* | 78 |
Perio Cleaning (following therapy) | 119 |
Full Mouth Debridement | 221 |
Curettage, scaling or planing (per quadrant) | 182 |
Gingivectomy per quadrant (includes post surgical visits) | 432 |
Osseous or muco-gingival surgery (per quadrant, includes post surgical visits) | 610 |
Gingivectomy (per tooth) | 134 |
Endodontics | |
Pulp capping | 63 |
Pulpotomy | 177 |
Anterior root canal therapy | 468 |
Bicuspid root canal therapy | 587 |
Molar root canal therapy | 712 |
Apicoectomy (separate procedure, excludes molars) | 419 |
Prosthetics | |
Resin/Acrylic Partial w/cast clasps | 899 |
Cast Partial, resin saddles (6 teeth, 2 clasps) (additional teeth $25 each, additional saddles $60 each) |
1012 |
High quality upper/lower denture (per arch) | 1108 |
Immediate Denture (will need to be relined) | 1255 |
Stayplate/Flipper(u/l up to 2 teeth, office only) | 445 |
Denture adjustments | 59 |
Reline, denture or partial (office) | 189 |
Reline, denture or partial (laboratory) | 266 |
Broken denture repair (no teeth involved) | 93 |
Replace tooth (includes lab fee) | 108 |
All materials used are ADA approved. |
Special Notes: |
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