| Dental Services | Member Charges |
| 9430 Office Visit | $ 5.00 |
| 0120 Oral Exam/Periodic Exam | NO CHARGE |
| 0140 Emergency Exam (during regular office hours- in addition to treatment charges) | 25.00 |
| 0150 Comprehensive Oral Evaluation | NO CHARGE |
| 0460 Vitality Test | NO CHARGE |
| 0470 Diagnostic Cast | NO CHARGE |
| Dental Services | Member Charges |
| 0210/0330 Full/Panoramic | NO CHARGE |
| 0220 Intra Oral/Single | NO CHARGE |
| 0230 Intra Oral/Each Additional | NO CHARGE |
| 0272 Bitewings, 2 Films | NO CHARGE |
| 0274 Bitewings, 4 Films | NO CHARGE |
| Dental Services | Member Charges |
| 1110 Prophylaxis (One per Six Months-Adult) | NO CHARGE |
| 1110 Additional Prophylaxis | $20.00 |
| 1120 Prophylaxis (One per Six Months-Child) | NO CHARGE |
| 1203 Topical Application of Fluoride (Annually) | NO CHARGE |
| 1330 Preventive Dental Instructions | NO CHARGE |
| 1350 Sealants (Per Quad/3 or More Teeth) | 25.00 |
| 1351 Sealants (Per Tooth) | 9.00 |
| 1510 Space Maintainer (Fixed Unilateral) | 55.00 |
| Dental Services | Member Charges |
| 2110 Amalgam-One Surface (Child) | $10.00 |
| 2120 Amalgam-Two Surfaces (Child) | 20.00 |
| 2130 Amalgam-Three Surfaces (Child) | 30.00 |
| 2140 Amalgam-One Surface (Adult) | 10.00 |
| 2150 Amalgam-Two Surfaces (Adult) | 20.00 |
| 2160 Amalgam-Three Surfaces (Adult) | 30.00 |
| 2161 Amalgam-Four Surfaces (Adult) | 45.00 |
| ALL AMALGAMS-2ND YEAR ON PLAN | NO CHARGE |
| 2330 Resin-One Surface (Anterior) | 45.00 |
| 2331 Resin-Two Surfaces (Anterior) | 55.00 |
| 2332 Resin-Three Surfaces (Anterior) | 65.00 |
| ABOVE RESINS-2ND YEAR ON PLAN (ANTERIOR) | NO CHARGE |
| 2520 Inlays-Two Surfaces | $210.00 + Lab |
| 2530 Inlays-Three Surfaces | 225.00 + Lab |
| 2940 Sedative Base | NO CHARGE |
| 2960 Laminates Per Tooth (Resin) | 175.00 |
| Dental Services | Member Charges |
| 2740 Crown - Porcelain | $245.00 |
| 2750/6240/6750 Crown Porcelain Fused to Precious Metal |
325.00 |
| 2751/6241/6751 Crown Porcelain Fused to Base Metal |
245.00 |
| 2752/6242/6752 Crown Porcelain Fused to Semi-precious Metal |
275.00 |
| 2791/6211/6791 Crown Fullcast to Base Metal |
245.00 |
| 2792/6212/6792 Crown Fullcast to Semi-precious Metal |
325.00 |
| 2840 Temporary Crown with Permanent | NO CHARGE |
| 2920 Recement Crown | NO CHARGE |
| 2930/2931 Crown - Stainless Steel | 65.00 |
| 2950 Core Buildup (Including any Pins) | 95.00 |
| 2952 Post & Core (With Root Canal) | 95.00 |
| 2998 Connection Over Three (Each) | 35.00 |
| Dental Services | Member Charges |
| 3220 Pulpotomy (Excluding Restoration) | $ 25.00 |
| 3310 Anterior Canal Filling (Excluding Final Restoration) |
150.00 |
| 3320 Bicuspid (Excluding Final Restoration) |
200.00 |
| 3330 Molar (Excluding Final Restoration) |
300.00 |
| 3410 Apicoectomy (Anterior Tooth) | 125.00 |
| Dental Services | Member Charges | 4210 Gingivectomy/Gingivoplasty (Per Quadrant) (Includes Post Surgical Visit) |
$175.00 |
| 4260 Osseous Surgery (Per Quadrant) | 275.00 |
| 4271 Free Gingival Graft (Per Procedure) |
UCR |
| 4310 Examination, Treatment Plan, Charting | 30.00 |
| 4341 Scaling, Root Planning (Per Quadrant) | 60.00 |
| 4355 Full Mouth Debridement | 45.00 |
| 4910 Periodontal Maintenance (After Perio Surgery) |
50.00 |
| 9940 Night Guard (Hard) | 175.00 |
| 9941 Night Guard (Soft) | 55.00 |
| 9951 Occlusal Adjustment Single Treatment, Limited |
35.00 |
| 9952 Occlusal Adjustment Complete Treatment |
160.00 |
| Dental Services | Member Charges |
| 5110/5120 Complete Denture (Upper/Lower) | $275.00 |
| 5111/5121 Cosmetic Denture (Upper/Lower) | 395.00 |
| 5130/5140 Immediate Denture (Upper/Lower) | 275.00 |
| 5210 Acrylic Partial (Upper/Lower - No Clasp) |
150.00 |
| 5211/5212 Acrylic Partial (Upper/Lower - 2 Clasps) |
250.00 |
| 5213/5214 Cast Chrome Partial (Upper/Lower - 2 Clasps) |
365.00 |
| 5730/31/40/41 Reline Complete/Partial Upper/Lower (Office) |
55.00 |
| 5750/51/60/61 Reline Complete/Partial Upper/Lower (Lab) |
55.00 + Lab |
| 5850/5851 Soft Tissue Conditioning | 35.00 |
| 5899 Denture Cleaning | NO CHARGE |
| Dental Services | Member Charges | 5410/5411 Denture Adjustment | $ 7.00 |
| 5510 Complete Upper/Lower (No Teeth) |
20.00 + Lab |
| 5520 Complete Upper/Lower (Replace Each Tooth) |
20.00 + Lab |
| 5640 Partial Upper/Lower (One Tooth) |
20.00 + Lab |
| 5650 Add to Partial to Replace Each Tooth | 20.00 + Lab |
| 5630 Repair Clasps | 20.00 + Lab |
| Dental Services | Member Charges |
| 7110 Extraction, Single (Simple) Up to Two (2) |
NO CHARGE |
| 7120 Additional Extractions 3 or More (Each) |
$ 25.00 |
| 7210 Surgical Extraction (By Definition) |
45.00 |
| 7220 Impaction, Soft Tissue | 55.00 |
| 7230 Impaction, Partial Bony | 65.00 |
| 7240 Impaction, Full Bony | 100.00 |
| 7250 Surgical Extraction of Residual Roots | 50.00 |
| 7310 Alveoloplasty, With Extraction Per Quadrant |
75.00 |
| 7510 Incise and Drain | 35.00 |
| 7960 Frenectomy | 85.00 |
| Dental Services | Member Charges | 8020 Initial Consultation (Including Examination, X-rays, Models and Records) |
$ 85.00 |
| 8460 The Maximum Orthodontic Fee for Normal, Class I Malocclusion 24 Month Fully Banded Case Will Not Exceed |
2,100.00 |
| 8560 Adults (20 Years and Over) Class I Malocclusion |
2,500.00 |
| Dental Services | Member Charges |
| 9215 Local Anesthetic | NO CHARGE |
| 9320 Nitrous Oxide | USUAL FEE |
| 9440 Emergency Visit (After Regular Office Hours in Addition to Treatment Charges) |
$50.00 |
| 9490 Appointment Cancellation (Less than 24-hours Notice) For Each 15-Minute Unit (Max $50.00) |
25.00 |