|
PROCEDURE DESCRIPTION
|
Usual Fee
|
Discounted Fee (for Plan Members)
|
Member Savings
|
| INITIAL ORAL EXAM |
$169 |
$0 |
$69 |
| FULL MOUTH X RAYS |
$114 |
$0 |
$114 |
| PANORAMIC FILM |
$97 |
$65 |
$32 |
| Teeth Cleaning |
$95 |
$45 |
$50 |
| White Filling, One Surface, Front Tooth |
$135 |
$89 |
$46 |
| Root Canal Treatment - Molar |
$919 |
$648 |
$271 |
| Single Crown – Porcelain on Metal |
$981 |
$625 |
$356 |
| Single Crown - Porcelain on Gold |
$1299 |
$899 |
$400 |
| Perio Scaling and Root Planing (Per Quadrant) |
$249 |
$146 |
$103 |
| Partial Denture (Upper or Lower) |
$1450 |
$890 |
$560 |
| Full Denture (Upper or Lower) |
$1375 |
$850 |
$525 |
| Simple Extraction |
$195 |
$120 |
$75 |
| Surgical Extraction |
$290 |
$165 |
$125 |
| Wisdom Teeth Extraction (Soft Tissue) |
$385 |
$249 |
$136 |
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