1.
Diagnostic |
| Covered
Services |
Member
Pays |
| All
necessary X-rays (once per year) |
No
Charge |
| Oral
exam/initial visit |
No
Charge |
| Oral
exam/periodic |
No
Charge |
| Vitality test |
No
Charge |
| Oral Cancer
exam |
No
Charge |
| Diagnostic cast |
No
Charge |
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2.
Preventive Care |
| Covered
Services |
Member
Pays |
| Cleaning
(one every six months) |
No
Charge |
|
Topical
application of fluoride (annually) |
No
Charge |
| Additional
cleanings |
$15 |
|
Sealant
(per tooth) |
$10 |
| Preventive
dental instructions |
No
Charge |
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3.
Restorative(Fillings) |
| Covered
Services |
Member
Pays |
| Sedative
base |
No
Charge |
Amalgam
- one surface |
$10 |
| Amalgam
- two surfaces |
$20 |
| Amalgam
- three surfaces |
$30 |
| Composite
- one surface |
$16 |
| Composite
- two surfaces |
$26 |
| Composite
- three surfaces |
$34 |
Acid
etch, add
|
$10 |
| Inlays - two
surfaces* |
$210 |
Inlays -
three surfaces*
*Gold additional |
$225 |
Bonding (light
cured composite):
Including acid etch:
One surface
Two surfaces
Three surfaces
Laminates per tooth |
$50
$70
$95
$175
|
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4.
Crown (Caps) |
| Covered
Services |
Member
Pays |
| Recement
inlays |
No
Charge |
| Temporary
crown |
No
Charge |
| Crown
- porcelain fused to non-precious metal |
$220 |
| Crown
- porcelain fused to semi-precious metal |
$245 |
| Crown
- porcelain fused to precious metal |
$290 |
| Crown
- full cast |
$225 |
| Core
build-up with pin (in addition to above) |
$90 |
| Core
with post (in addition to above) |
$90 |
| Crown
- stainless steel (primary teeth) |
$50 |
| Connection
over three, each |
$30 |
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5.
Endodontics (Root Canal) |
| Covered
Services |
Member
Pays |
| Pulpotomy
(excluding restoration) |
$20 |
| Single
root canal filling (excluding final restoration) |
$125 |
| Bi-root
canal filling (excluding final restoration) |
$185 |
| Tri-root
canal filling (excluding final restoration) |
$280 |
| Apicoectomy |
$85 |
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6.
Periodontics (Gum Treatment) |
| Covered
Services |
Member
Pays |
| Periodontal
prophylaxis (after periosurgery) |
$50 |
| Examination,
treatment plan |
$30 |
| Periodontal,
root planning & curettage per quadrant |
$225
$65 |
| Gingivectomy
or Gingivoplasty (includes post surgical
visit) - per quadrant |
$160
|
| Osseous surgery
(per quadrant) |
$250
|
| Free gingival
graft |
$225 |
| Occlusal adjustment,
single treatment |
$35 |
| Occlusal adjustment,
complete treatment |
$160 |
| Night guard
- soft |
$55 |
| Night guard
-hard |
$175 |
| Gross scaling
in presence of gingival inflammation |
$35 |
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7.
Prosthodontics |
| Covered
Services |
Member
Pays |
| Acrylic
partial (upper or lower) each |
$105 |
| Complete
upper |
$240 |
| Complete
lower |
$240 |
| Immediate
upper or lower |
$250 |
| Cast
chrome partial - upper (unlimited clasps) |
$325 |
| Cast
chrome partial - lower (unlimited clasps) |
$325 |
| Cosmetic
denture, upper or lower |
$350 |
| Repair
broken denture |
$35 |
| Add
or replace tooth to denture with
impression
Each additional tooth |
$40
$15 |
| Add
or replace tooth to denture with no impression |
$18 |
| Soft
liner (additional) |
$85 |
| Denture
adjustment (old) |
$7 |
| Denture
cleaning |
No
Charge |
| Reline
upper or lower partial or complete denture
(office) |
$55 |
| Reline
upper or lower partial or complete denture
(lab) |
$85 |
| Add
clasp to existing denture/partial |
$50 |
| Soft
tissue conditioner |
$35 |
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8.
Orthodontics (Braces) - children up to age 19
only |
| Covered
Services |
Member
Pays |
|
Initial consultation, including examination,
x-rays
models and records |
$85
|
| The
maximum orthodontic fee for normal 24
month fully banded case will not exceed |
$2100
|
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9.
Oral Surgery |
| Covered
Services |
Member
Pays |
| Extraction
(Simple) each tooth |
No
Charge |
| Post-operative
treatment |
No
Charge |
| Tori
removal |
$50 |
| Cyst removal
(less than 5 mm) |
$50 |
| Alveolectomy
(per quadrant) |
$70 |
| Impaction (soft
tissue) |
$45 |
| Multiple extraction
3 or more (each) |
$10 |
| Surgical extraction |
$35 |
| Surgical extraction
of residual roots |
$35 |
| Impaction (partial
bony) |
$65 |
| Impaction (complete
bony) |
$95 |
| Incise and drain |
$25 |
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10.
Miscellaneous |
| Covered
Services |
Member
Pays |
| Appointment
cancellation (more than 24 hour notice) |
No
Charge |
| Appointment
cancellation (less than 24-hour notice)
for each 15 minute unit |
$10
|
| Local anesthetic |
No
Charge |
| Temporary filling |
No
Charge |
| Emergency treatment
(during regular office hours in addition
to treatment charges) |
$25
|
| Emergency treatment
(after regular office hours in addition
to treatment charges) |
$35
|
The member charges listed are valid only when
treatment is performed at a participating general
dental office. If the service of a specialist
are required, then the charge will be the specialist’s
usual and customary fee, less discount of 20%.
Any services not listed will be available at
the dentist’s usual and customary fees less
discount of 20%.
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