| Procedure Description |
Usual Fee 1 |
Discounted Fee 2 (for Plan Members) |
Member Savings |
| Routine 6 Month Check-Up |
$43 |
$20 |
$23 |
| In Depth Check-Up * |
$69 |
$0 |
$69 |
| Full Mouth X-Rays |
$114 |
$58 |
$56 |
| Four Bitewing X-Rays |
$55 |
$29 |
$26 |
| Panoramic Film |
$97 |
$58 |
$39 |
| Adult Teeth Cleaning |
$83 |
$49 |
$34 |
| Child Teeth Cleaning |
$62 |
$27 |
$35 |
| Protective Sealant / Tooth |
$46 |
$27 |
$19 |
| 1 Surface White Filling for U or L Front Tooth |
$135 |
$80 |
$55 |
| Single Crown - Porcelain on High Noble Metal |
$981 |
$595 |
$386 |
| Single Crown - Porcelain on Noble Metal |
$912 |
$575 |
$337 |
| Core Build-Up With Pins |
$238 |
$130 |
$108 |
| Root Canal Treatment - Front Tooth |
$636 |
$450 |
$186 |
| Root Canal Treatment - Bicuspid |
$757 |
$500 |
$257 |
| Root Canal Treatment - Molar |
$919 |
$625 |
$294 |
| Perio Scaling and Root Planing (Per Quadrant) |
$217 |
$105 |
$112 |
| Full Upper Denture |
$1,353 |
$700 |
$653 |
| Tooth Replacement Part of Permanent Bridge |
$911 |
$525 |
$386 |
| Single Tooth Removal - Surgical Extraction |
$138 |
$81 |
$57 |
|
Child Sample Fees |
| Routine 6 Month Check-Up |
$43 |
$18 |
$25 |
| In Depth Check-Up * |
$69 |
$0 |
$69 |
| Full Mouth X-Rays |
$114 |
$52 |
$62 |
| Four Bitewing X-Rays |
$55 |
$23 |
$32 |
| Panoramic Film |
$97 |
$42 |
$55 |
| Child Teeth Cleaning |
$62 |
$27 |
$35 |
| Protective Sealant / Tooth |
$46 |
$20 |
$26 |
| 1 Surface White Filling for U or L Front Tooth |
$135 |
$60 |
$75 |
| Single Crown - Porcelain on High Noble Metal |
$981 |
$575 |
$406 |
| Single Crown - Porcelain on Noble Metal |
$912 |
$540 |
$372 |
| Core Build-Up With Pins |
$238 |
$90 |
$148 |
| Root Canal Treatment - Front Tooth |
$636 |
$400 |
$236 |
| Root Canal Treatment - Bicuspid |
$757 |
$450 |
$307 |
| Root Canal Treatment - Molar |
$919 |
$590 |
$329 |
| Perio Scaling and Root Planing (Per Quadrant) |
$217 |
$84 |
$133 |
| Single Tooth Removal - Surgical Extraction |
$138 |
$61 |
$77 |