|
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
|
