|
PROCEDURE DESCRIPTION
|
Usual Fee
|
Discounted Fee (for Plan Members)
|
Member Savings
|
| INITIAL ORAL EXAM |
$169 |
$0 |
$169 |
| FULL MOUTH X RAYS |
$114 |
$0 |
$114 |
| PANORAMIC FILM |
$97 |
$65 |
$32 |
| Teeth Cleaning |
$95 |
$45 |
$50 |
| White Filling, One Surface, Front Tooth |
$195 |
$111 |
$84 |
| Root Canal Treatment - Molar |
$1200 |
$738 |
$462 |
| Single Crown – Non Metal (Zirconia) |
$1250 |
$950 |
$300 |
| Single Crown - Porcelain on Gold |
$1299 |
$800 |
$499 |
| Perio Scaling and Root Planing (Per Quadrant) |
$249 |
$176 |
$73 |
| Partial Denture (Upper or Lower) |
$1650 |
$1200 |
$450 |
| Full Denture (Upper or Lower) |
$1650 |
$1200 |
$450 |
| Simple Extraction |
$195 |
$145 |
$50 |
| Surgical Extraction |
$290 |
$185 |
$105 |
| Wisdom Teeth Extraction (Soft Tissue) |
$401 |
$300 |
$101 |
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