PREVENTIVE DENTAL CARE
|
SMILES PLUS PLAN FEES* |
PREVAILING FEES+ |
| Examination (Up to two per year) |
 |
(Per Exam) $75.00 |
Treatment Planning (Two per year) |
|
$49.00 |
X-Rays Up to Full Series (One per year) |
|
$120.00 |
Cleaning-Prophylaxis (One per year) |
|
$70.00 |
Fluoride Treatment for Children (One per year) |
|
$37.00 |
| CORRECTIVE DENTAL SERVICES |
|
|
| Scaling (Per Quadrant) |
$104.00 |
$225.00 |
| Filling: (Amalgam or Composite) |
|
|
| 1 Surface |
|
|
| 2 Surfaces |
|
|
| 3 Surfaces |
|
|
| ORAL SURGERY (LOCAL ANESTHESIA ONLY) |
|
|
| Simple Extraction |
$90.00 |
$120.00 |
| Surgical Extraction |
$104.00 |
$155.00 |
| Soft Tissue Impaction |
$208.00 |
$285.00 |
| Partial Bony Impaction |
$247.50 |
$325.00 |
| Full Bony Impaction |
$324.50 |
$385.00 |
| ROOT CANAL THERAPY |
|
|
| RCT -1 Canal |
$445.00 |
$650.00 |
| RCT -2 Canals |
$571.00 |
$750.00 |
| RCT -3 Canals |
$632.50 |
$950.00 |
| REMOVABLE PROSTHETICS & REPAIRS |
|
|
| Full Upper/Lower Denture |
$695.00 |
$950.00 |
| Partial Upper/Lower Denture (Cast) |
$795.00 |
$1,300.00 |
| Partial Upper or Lower Denture (Flexi) |
$790.00 |
$1,950.00 |
| Repair Body of Denture |
$110.00 |
$235.00 |
| Replace Tooth of Denture $ |
$70.00 |
$175.00 |
| Add New Clasp to a Partial |
$93.50 |
$250.00 |
| Denture Reline |
$164.00 |
$350.00 |
| CROWN AND BRIDGE |
|
|
| Porcelain Fused to Metal Crown (Individual) |
$544.50 |
$950.00 |
| Porcelain Fused to Metal Crown/Abutment,Pontic (Per Crown) |
$544.50 |
$950.00 |
| Zirconia Crown (Per Crown) |
$600.00 |
$1,100.00 |
| Cast Post & Core |
$160.00 |
$240.00 |
| ORTHODONTIA |
|
|
| Insertion of Bands and/or Appliance $ |
$950.00 |
$1,510.00 |
| Monthly Adjustments of Active and Passive (per month) |
$164.00 |
$200.00 |
| COSMETIC DENTISTRY |
|
|
| In Office Teeth Whitening |
$249.00 |
$299.00 |
| Custom Tray Power Whitening |
$149.00 |
$299.00 |
| Laminates/Veneers (per tooth) |
$650.00 |
$1,200.00 |
| OTHER TREATMENT |
|
|
| Specialty Consultation |
$55.00 |
$150.00 |
| Emergency Palliative Treatment |
$65.00 |
$95.00 |
| Broken Appointment |
$25.00 |
$25.00 |
