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Office Visit
Office Visit
 $5
Diagonstic Care
Oral Exams
 No Charge
X-rays
 No Charge
Preventive Care
Prophylaxis - adult & child
 No Charge1
Topical Fluoride - child
 No Charge
Restorative Care
Filling - Permanent 1 surface amalgam
 No Charge2
Filling - Permanent 2 surfaces amalgam
 No Charge2
Filling - Permanent 3 surfaces amalgam
 No Charge2
Filling - Permanent 4 or more surfaces amalgam
 No Charge2
Cosmetic Care
Labial Veneer(laminate)-chairside
 $187
Resin Filling - permanent,one surface, posterior
 $75
Endodontic Care
Pulpotomy
 $62
Root Canal - Anterior
 $289
Root Canal - Bicuspid
 $341
Root Canal - Molar
 $459
Periodontal Care
Gingivectomy - per quadrant
 $194
Gingivectomy - per tooth
 $72
Osseous Surgery
 $520
Scaling/Root Planingper quadrant
 $101
Oral Surgery
Extraction - of erupted toothor expossed root
 $60
Impaction - complete bony
 $200
Impaction - partial bony
 $176
Impaction - soft tissue
 $136
Prosthodontic Care
Complete Upper or
 $577
Crowns
 $432
Denture (broken tooth repair)
 $57
Partial Denture
 $430
Orthodontic Care
Orthodontics - Adult
 $3045
Orthodontics - Child
 $2870
Retention
 $210
Other Services
Local Anesthesia
 $14
Office Visit After Hours
 $56
1 First two treatments in 12 consecutive months. All additional treatments within a 12 month period require copayments of $44 for adults and $35 for children.
2 You must meet a six-month waiting period before these benefits are payable.
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Copyright © 2005 Oleg Skurskiy Authorized Independent Agent, CA License 0E50389