Fee Schedule #36
| Clinical Oral Evaluation | Members' Cost |
| 0120 Periodic oral evaluation |
$38.00 |
| 0140 Emergency oral evaluation |
$48.00 |
| 0150 Comprehensive oral evaluation |
$58.00 |
| 0180 Comprehensive periodontal evaluation |
$59.00 |
| Radiographic Diagnostic Imaging | |
| 0210 Intraoral - complete series |
$92.00 |
| 0220 Intraoral - periapical first film |
$22.00 |
| 0230 Intraoral - periapical each additional film |
$19.00 |
| 0270 Bitewing - single film |
$22.00 |
| 0272 Bitewing - two films |
$36.00 |
| 0274 Bitewing - four films |
$47.00 |
| Preventive Services | |
| 1110 Prophylaxis - adult |
$69.00 |
| 1120 Prophylaxis - child |
$54.00 |
| 1203 Topical application of fluoride child |
$30.00 |
| 1204 Topical application of fluoride adult |
$30.00 |
| 1310 Nutritional counseling |
No Fee |
| 1330 Oral hygiene instructions |
No Fee |
| 1351 Sealant - per touch |
$39.00 |
| Amalgam Restoration | |
| 2140 Amalgam - one surface, primary or perm |
$95.00 |
| 2150 Amalgam - two surfaces, primary or perm |
$116.00 |
| 2160 Amalgam - three surfaces, primary or perm |
$142.00 |
| 2161 Amalgam - four + surfaces, primary or perm |
$191.00 |
| Resin Based Composite Restorations | |
| 2330 Resin based composite - one surface, anterior |
$114.00 |
| 2331 Resin based composite - two surface, anterior |
$149.00 |
| 2332 Resin based composite - three surfaces, anterior |
$189.00 |
| 2335 Resin based composite - four + surfaces or involving incisal angle, anterior |
$211.00 |
| 2391 Resin based composite - one surface posterior |
$125.00 |
| 2392 Resin based composite - two surfaces posterior |
$192.00 |
| 2393 Resin based composite - three surfaces, posterior |
$228.00 |
| 2394 Resin based composite - four + surfaces posterior |
$261.00 |
| Crowns Single Restorations | |
| 2720 Crown - resin with high noble metal |
$788.00 |
| 2740 Crown - porcelain/ceramic subtrate |
$840.00 |
| 2750 Crown - porcelain fused to high noble metal |
$788.00 |
| 2752 Crown - porcelain fused to noble metal |
$788.00 |
| 2791 Crown - full cast predominantly base metal |
$760.00 |
| 2792 Crown - full cast noble metal |
$788.00 |
| Other Restorative Services | |
| 2910 Recement inlay |
$75.00 |
| 2920 Recement crown |
$75.00 |
| 2931 Prefabricated stainless steel crown - primary |
$259.00 |
| 2940 Sedative filling |
$86.00 |
| 2950 Core build-up, including any pins |
$207.00 |
| 2952 Cast post & core in addition to crown |
$281.00 |
| Endodontics | |
| 3110 Pulp cap - direct (excl. final rest.) |
$63.00 |
| 3220 Pulp cap - indirect (excl. final rest.) |
$144.00 |
| 3310 RCT anterior (excl. final rest.) |
$589.00 |
| 3320 RCT bicuspid (excl. final rest.) |
$680.00 |
| 3330 RCT molar (excl. final rest.) |
$809.00 |
| Periodontal Services | |
| Straight 20% Savings | |
| Prosthetics | |
| Straight 20% Savings | |
| Oral Surgery | |
| Straight 20% Savings | |
| Orthodontics | |
| Consultation, Diagnostics, upper/lower banding, retainers (up to 2 years) | |
| Orthodontics under age of 19 |
$4600.00 |
| Orthodontics over age of 19 |
$5000.00 |
| At the orthodontic consultation, the Orthodontist will explain the length of treatment, all fees, and the payment schedule. The above fees are for a standard orthodontic treatment of 24 months. There will be additional charges for special cosmetic appliances, and extended treatments that require surgery, broken or lost appliances, and treatment time due to lack of cooperation. | |
| Orthodontic treatments not listed on this fee schedule such as early partial treatments or orthopedic treatments will be billed at 15% less than the provider's usual and customary fee. | |
| Special Dental Services | |
| Treatment provided by a participating specialist (ie; oral surgeon, Periodontics or Endodontics) will be billed at a 20% reduction from the provider's usual customer fee. Please discuss all fees with specialist prior to beginning treatment. | |
| Dental Services Not Listed | |
| Dental procedures not listed is available on a fee for service basis and will be billed 20% below the provider's usual and customary fee. | |
| Payment For Dental Services | |
| Payment for dental services must be made to the dental office at time of service. For your convenience the use of a major credit card is accepted. | |
| Miscellaneous Charges | |
| Failed appointment |
$45.00 |
| Fee Schedule #34 effective February 1, 2008 |
