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Plan Details



  when services are rendered by a participating general dentist
Diagnostic & Preventive Services  
Oral Exam No Charge
Full Mouth X-rays No Charge
Single Films No Charge
Bitewing Series No Charge
Oral Hygiene Instruction No Charge
Cleaning of Teeth (polishing) No Charge
Fluoride Treatment No Charge
Emergency Treatment No Charge
Sealant* No Charge
*For dependent children between 5 and 15 years of age, restricted to previously unrestored permanent first and second molars, permitted once every five (5) years.
Restorative Dentistry Primary and Permanent  
Silver amalgam, one surface $20.00
Silver amalgam, two surfaces $35.00
Silver amalgam, three surfaces or more $50.00
Composite filling, one surface $25.00
Composite filling, two surfaces $40.00
Composite filling, three surfaces or more $55.00
*Oral Surgery  
Routine Extractions - per tooth $45.00
Surgical Extraction $75.00
Soft Tissue Impaction $95.00
Partial Bony Impaction $125.00
Full Bony Impaction $160.00
Alveolectomy, per quad $95.00
*Root Canal Therapy  
Pulp Capping $10.00
Pulpotomy $35.00
Root Canal Therapy-Anterior $225.00
Root Canal Therapy-Bicuspid $290.00
Root Canal Therapy-Molar $395.00
Apicoectomy $175.00
Scaling of teeth, per quad $25.00
Gingivectomy, per quad $125.00
Osseous surgery, per quad $425.00
Prosthetics - Crowns  
Acrylic with metal crown $295.00
Porcelain crown $385.00
Porcelain w/ metal crown $425.00
Stainless steel crown $95.00
Cast post $95.00
Recementation, per crown $35.00
Prosthetics - Fixed Bridges  
Acrylic w/ metal bridge crown or pontic $295.00
Porcelain w/ metal bridge crown or pontic $425.00
Recementation, bridge $35.00
Prosthetics - Removable  
Full upper denture, inc. adjustments $395.00
Full lower denture, inc. adjustments $395.00
Partial upper denture, cast base and acrylic $395.00
Partial lower denture, cast base and acrylic $395.00
Denture Adjustments (for denture not made in office) $35.00
Prosthetics - Repairs  
Broken body of denture (no teeth involved) $95.00
Replacing broken, missing teeth $35.00
Office Reline $95.00
Lab Reline $150.00
Maximum Case Fee - 24 months 75% UCR

* When a participating specialist renders these services, the copayment will be 25% less than specialist's usual fees.

Waiting Periods on Types of Services
Preventive None
Diagnostic None
Basic None
Major None
Orthodontia None

Preventive care
  • Routine oral exams - once every six months
  • Prophylaxis (cleaning and scaling of teeth) - once every six months
  • Topical application of fluoride – once every six months
Diagnostic care
  • Bitewing x-rays - once every six months
  • Full-mouth x-rays and panoramic x-rays– once every three years
Basic care
  • Simple extraction
  • Pin retention – per tooth, in addition to restorations
  • Fillings (restorations) – amalgam restorations, composite restorations for anterior teeth and bicuspids, and sedative fillings
Major care
  • Endodontic treatment
  • Periodontic services – (surgery) once every 60 months
  • Crowns - once every 60 months
  • Prosthodontic services – dentures or bridges – once every 60 months
  • Oral surgery
  • When a participating specialist renders these services, the co-payment will be 25% less than the specialist’s usual fees.