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General Dentist Fees  Diagnostic Initial / Periodic Exam Free Limited Exam Free Comprehensive Exam Free Intraoral Complete Series $50.00 Intraoral Single Film $14.00 Intraoral Addt'l Film $14.00 Bitewing - Two Films $15.00 Bitewing - Four Films $20.00 Panoramic Film $50.00 Pulp Vitality Tests $15.00 Diagnostic Casts Free Preventive Adult Prophylaxis $60.00 Child Prophylaxis $40.00 Fluoride - Child $20.00 Sealant (per tooth) $30.00 Space Maint. - fixed unilat. $225.00 Space Maint. - rem. unilat. $225.00 Space Maint. - fixed bilat. $275.00 Space Maint. - rem. bilat. $275.00 Restorative Amalgam (silver)  One Surf - Prim. or Perm. $65.00 Two Surf - Prim. or Perm. $80.00 Three Surf - Prim. or Perm. $90.00 Four+ Surf - Prim. or Perm. $120.00 Resin (white) One Surface - Anterior $75.00 Two Surface - Anterior $90.00 Three Surface - Anterior $115.00 Four+ Surface or Incisial $140.00 One Surface - Posterior Perm. $85.00 Two Surface - Posterior Perm. $110.00 3+ Surface - Posterior Perm. $155.00 Inlay/Onlay Metal or Porcelain  2 Surface Inlay - metal $275.00 2 Surface Onlay - metal $295.00 3 Surface Onlay - metal $395.00 4+ Surface Onlay - metal $495.00 2 Surface Inlay - Porcelain $340.00 3+ Surface Inlay - Porcelain $440.00 2 Surface Onlay - Porcelain $375.00 3 Surface Onlay - Porcelain $440.00 4+ Surface Onlay - Porcelain $490.00 Crowns-Single Restoration   Listed procedures include lab fees Lab Resin $110.00 Porcelain - High Noble Metal $680.00 Porcelain - Base Metal $680.00 Porcelain - Noble Metal $680.00 Full Cast - High Noble Metal $680.00 3/4 Cast - High Noble Metal $680.00 Re-cement Crown $45.00 Sedative Filling $50.00 Core Buildup $140.00 Post/Core - cast $240.00 Prefab Post/Core $165.00 Labial Veneer - chairside $550.00 Labial Veneer - lab $695.00 Temp Crown - (frac.tooth) $100.00  Endodontics  Pulp Cap - Direct                    $35.00 Pulp Cap - Indirect $35.00 Pulpotomy $75.00 Root Canal - Anterior $355.00 Root Canal - Bicuspid $415.00 Root Canal - Molar $550.00 Apicoectomy - Anterior $450.00 Apicoectomy - Bicuspid $495.00 Apicoectomy - Molar $575.00 Retrograde Fill (per root) $120.00 Periodontics  Gingivectomy - perquad $185.00 Gingivectomy - (1-3 teeth) $75.00 Osseous Surgery per quad              $450.00 Splinting - Intracoronal $140.00 Splinting - Extracoronal $140.00 Scale/Root Planing - Per Quad $90.00 Periodontal Maintenance $70.00 Full Mouth Debridement $60.00  Adjunctive General Services  Palliative Treatment / Emergency $70.00 Office visit - after hours $110.00 Occlusal Guard $295.00 Athletic Mouthguard $295.00 Consultation (2nd opinion or extensive treatment plan) $45.00 Bleaching (per arch) $195.00 Esthetic recontoring (per tooth) $30.00 Removable Prosthodontics   Listed procedures include lab fees   Complete Dentures excludes extractions Complete Upper                             $710.00 Complete Lower $710.00 Immediate Upper $725.00 Immediate Lower $725.00  Partial Dentures  Upper - Resin Base $700.00 Lower - Resin Base $700.00 Upper - Cast Metal $700.00 Lower - Cast Metal $700.00 Upper - Complete Adjustment $45.00 Lower - Complete Adjustment     $45.00 Upper Partial Adjustment $45.00 Lower Partial Adjustment $45.00 Interim Partial - Upper $315.00 Interim Partial - Lower $315.00 Unilateral-Nesbeth $250.00  Denture Repairs  Repair - Complete Base $95.00 Replace missing tooth                    $85.00 Repair Frame work $120.00 Add Clasp to Existing Partial $155.00 Rebase Upper (chairside) $215.00 Rebase lower (chairside) $215.00 Reline Upper (chairside) $175.00 Reline Lower (chairside) $175.00 Reline Upper (lab) $235.00 Reline Lower (lab) $235.00  Fixed Prosthodontics  Pontic $680.00 Crown (abutment)                            $680.00 Provisional Crown - Lab $110.00   Oral Surgery Extraction - erupted tooth or exposed root $85.00 Impacted Tooth - soft tissue $175.00 Partial Bony Impaction $250.00 Complete Bony $350.00 Root Removal - Surgical $140.00 Incision & Drainage $90.00 Non-listed procedures performed by General Dentists are provided to Members at a "courtesy fee" of 25% off the General Dentist's usual and customary fee. Specialist Fees  Diagnostic Periodic oral evaluation $45.00 Limited oral evaluation $55.00 Comprehensive oral evaluation $70.00 Complete series X-rays $80.00 X-ray periapical first film $17.00 X-rays periapical each additional $15.00 X-rays occlusal film $35.00 Bitewing - single film $20.00 Bitewings - two films $30.00 Bitewings - four films $45.00 X-rays Ant/Posterior Lateral Skull and facial bone survey $85.00 Panoramic Film $86.00 Cephalometric film $100.00 Diagnostic Casts $60.00 Diagnostic Photographs $40.00 Endodontics Pulp cap direct (excluding final restoration) $55.00 Pulp cap indirect (excluding final rest.) $60.00 Therapeutic Pulpotomy $135.00 Anterior Root Canal Therapy $450.00 Bicuspid Root Canal Therapy $550.00 Molar Root Canal Therapy $750.00 Retreatment - Anterior $525.00 Retreatment - Bicuspid $575.00 Retreatment - Molar $775.00 Apexification initial visit $250.00 Apexification interim visit $200.00 Apicoectomy Anterior $450.00 Apicoectomy Bicuspid first root $550.00 Apicoectomy Molar first root $635.00 Apicoectomy each additional root $330.00 Retrograde Filling per root $205.00 Root Amputation per root $295.00 Hemisection (not including RCT) $315.00 Internal bleaching per tooth $295.00 Periodontics Gingivectomy/gingivoplasty (per quad) $465.00 Gingivectomy/gingivoplasty (per tooth) $175.00 Gingival flap procedure including root planing per quad $495.00 Osseous surgery per quad $695.00 Bone replacement graft first site $525.00 Bone replacement graft each addt'l site $390.00 Pedicle soft tissue graft $575.00 Free soft tissue graft procedure $600.00 Periodontal scaling/root planing per quad $190.00 Full mouth debridement to enable comprehensive perio evaluation $145.00 Periodontal maintenance procedure $95.00 Oral Surgery Extraction - Erupted tooth or exposed root $180.00 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth $210.00 Removal of impacted tooth-soft tissue $290.00 Removal of impacted tooth-partial bony $380.00 Removal of impacted tooth-complete bony $420.00 Removal of impacted tooth-complete bony with unusual surgical complications $440.00 Surgical removal of residial roots $200.00 Surgical access of an unerupted tooth $350.00 Surgical exposure of impacted or unerupted tooth to aid eruption $350.00 Alveoplasty in conjuction with extractions per quadrant $275.00 Alveoplasty not in conjuction with extractions per quadrant $325.00 Removal of lateral exostosis per site $425.00 Incision and drainage of abscess $175.00 Frenulectomy $330.00 Excision of hyperplasic tissue - per arch $325.00 Excision of pericoronal gingiva $150.00 Orthodontics Diagnostic photographs $50.00 Comprehensive Treatment of Adolescent dentition - Partial Banding $2,050.00 Comprehensive Treatment of Adolescent dentition - Full Banding $4,000.00 Comprehensive Treatment of Adult dentition - Partial Banding $2,050.00 Comprehensive Treatment of Adult dentition - Full Banding $4,100.00 Orthodontic retention - removal of appliances, construction and placement of retainer(s) $440.00 Pediatric Dentistry Prophylaxis-child $70.00 Sealant-per tooth $40.00 Space Maintainer - fixed unilateral $275.00 Space Maintainer - fixed bilateral $370.00 Space Maintainer - removable unilateral $300.00 Space Maintainer - removable bilateral $350.00 Recement Space Maintainer $60.00 Amalgam - one surface $80.00 Amalgam - two surface $95.00 Amalgam - three surface $115.00 Amalgam - four or more surface $135.00 Prefab Stainless Steel Crown $175.00     Non-listed procedures performed by the Specialist are provided to all Members at a "courtesy fee" of 20% off the Specialist's usual and customary fee.    *Fees effective January 2008