Fee Schedules

General Dentist Fees

Diagnostic Crowns-Single Restoration Prosthodontics
Initial/Periodic Exam Free Listed procedures include lab fees Listed procedures include lab fees                                                   Complete Dentures exclude extractions
Limited Exam Free Lab Resin $110
Comprehensive Exam Free Porcelain – High Noble Metal $720 Complete Upper $775
Initial/Periodic Exam Free Porcelain – Base Metal $720 Complete Lower $775
Intraoral Complete Series $75 Porcelain – Noble Metal $720 Immediate Upper $815
Intraoral Single Film $14 Full Cast High Noble Metal $720 Immediate Lower $815
Intraoral Addt’l. Film $14 3/4 Cast High Noble Metal $720 Partial Dentures
Bitewing – Two Films $15 Recement Crown $55 Upper – Resin Base $815
Bitewing – Four Films $20 Sedative Filling $60 Lower – Resin Base $815
Panoramic Film $75 Core Build-up $155 Upper – Cast Metal $815
Pulp Vitality Tests $15 Post/Core – cast $275 Lower – Cast Metal $815
Diagnostic Casts $25 Prefab Post / Core $195 Upper – Complete Adjustment $45
Preventive Labial Veneer – chairside $550 Lower – Complete Adjustment $55
Adult Prophylaxis $80 Labial Veneer – lab $810 Upper Partial – Adjustment $55
Child Prophylaxis $55 Temp Crown – (frac. tooth) $110 Lower Partial – Adjustment $55
Fluoride – Child $25 Endodontics Interim Partial – Upper $360
Sealant (per tooth $40 Pulp Cap – Direct $35 Interim Partial – Lower $360
Space Maintainer -fixed unilat $225 Pulp Cap – Indirect $35 Unilateral – Nesbeth $360
Space Mainteiner – rem. unilat $225 Pulpotomy $85 Denture Repairs
Space Maintainer – fixed bilat $275 Root Canal – Anterior $390 Repair – Complete Base $125
Space Maintainer – rem. bilat $275 Root Canal – Bicuspid $445 Replace missing tooth $95
Restorative Root Canal – Molar $615 Repair Frame work $120
Amalgam (silver) Apicoectomy – Anterior $475 Add Clasp to Existing Partial $155
One Surf – Prim. or Perm. $75 Apicoectomy – Bicuspid $525 Rebase Upper (chairside) $215
Two Surf – Prim. or Perm. $90 Apicoectomy – Molar $675 Rebase lower (chairside) $215
Three Surf – Prim. or Perm. $110 Retrograde Fill  (per root) $120 Reline Upper (chairside) $175
Four + Surf – Prim. or Perm. $140 Periodontics Reline Lower (chairside) $175
Resin (white) Gingivectomy – per quad $185 Reline Upper (lab) $285
One Surface – Anterior $85 Gingivectomy  – 1-3 teeth $125 Reline Lower (lab) $285
Two Surface – Anterior $100 Osseous Surgery per quad $450 Fixed Prostodontics
Three Surface – Anterior $130 Splinting – Intracoronal $175 Pontic $720
`Four + Surface or Incisal $160 Splinting – Extracoronal $175 Crown (abutment) $720
One Surface – Posterior Perm. $95 Scale/Root Planning – Per Quad $120 Provisional Crown – Lab $110
Two Surface – Posterior Perm. $130 Periodontal Maintenance $80 Oral Surgery
3+ Surface – Posterior Perm. $180 Full Mouth Debridement $95 Extraction – erupted tooth or $115
Inlay/Onlay Metal or Porcelain Adjunctive General Services exposed root
2 Surface Inlay – metal $325 Palliative Treatment/Emergency $85 Impacted Tooth – soft tissue $205
2 Surface Onlay – metal $340 Office visit – after hours $150 Partial Bony Impaction $295
3 Surface Onlay – metal $450 Occlusal Guard $295 Complete Bony $395
4+ Surface Onlay – metal $595 Athletic Mouthguard $295 Root Removal – Surgical $190
2 Surface Inlay – Porcelain $525 Consultation (2nd opinion $45 Incision & Drainage $115
3+ Surface Inlay – Porcelain $600 or extensive treatment plan)
2 Surface Onlay – Porcelain $550 Bleaching (per arch) $195
3 Surface Onlay – Porcelain $625 Esthetic recontoring per tooth $30
4+ Surface Onlay – Porcelain $695
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 fees.Fees effective January 1, 2013

Specialist Fees

DIAGNOSTIC PERIODONTICS ORTHODONTICS
Periodic oral evaluation $47 Gingivectomy/gingivoplasty (per quad) $490 Diagnostic photographs $50
Limited oral evaluation $58 Gingivectomy/gingivoplasty (per tooth) $185 Comprehensive Treatment of
Comprehensive oral evaluation $75 Gingival flap procedure including Adolescent dentition – Partial Banding $2,150
Complete series X-rays $85 root planing per quad $520 Comprehensive Treatment of
X-rays periapical first film $20 Osseous surgery per quad $760 Adolescent dentition – Full Banding $4,200
X-rays periapical each additional $17 Bone replacement graft first site $550 Comprehensive Treatment of
X-rays occlusal film $40 Bone replacement graft  each addt’l site $415 Adult dentition – Partial Banding $2,150
Bitewing – single film $22 Pedicle soft tissue graft $600 Comprehensive Treatment of
Bitewing – two films $32 Free soft tissue graft procedure $625 Adult dentition – Full Banding $4,250
Bitewings – four films $47 Periodontal scaling/root planing per quad $200 Orthodontic retention – removal of appliances,
X-rays Ant/Post or Lateral Full mouth debridement to enable construction and placement of retainer(s) $460
Skull and facial bone survey $90 comprehensive perio evaluation $155
Panoramic Film $90 Periodontal maintenance procedure $100 PEDIATRIC DENTISTRY
Cephalometric film $105 Prophylaxis-child $72
Diagnostic Casts $65 ORAL SURGERY Sealant-per tooth $42
Diagnostic Photographs $42 Extraction – Erupted tooth or exposed root $190 Space Maintainer – fixed unilateral $285
Surgical removal of erupted tooth Space Maintainer – fixed bilateral $395
ENDODONTICS requiring elevation of mucoperiosteal Space Maintainer – removable unilateral $315
Pulp cap direct (excluding final restoration) $57 flap and removal of bone and/or Space Maintainer – removable bilateral $360
Pulp cap indirect (excluding final rest.) $62 section of tooth $220 Recement Space Maintainer $65
Theraputic Pulpotomy $140 Removal of impacted tooth-soft tissue $320 Amalgam – one surface $85
Anterior Root Canal Therapy $465 Removal of impacted tooth-part’l bony $400 Amalgam – two surface $100
Bicuspid Root Canal Therapy $570 Removal of impacted tooth-complete bony $440 Amalgam – three surface $120
Molar Root Canal Therapy $785 Removal of impacted tooth-complete bony Amalgam – four or more surface $140
Retreatment – Anterior $535 with unusual surgical complications $485 Prefab Stainless Steel Crown $185
Retreatment – Bicuspid $585 Surgical removal of residial roots $210
Retreatment – Molar $810 Surgical access of an unerupted tooth $365
Apexification initial visit $260 Surgical exposure of impacted or
Apexification interim visit $210 unerupted tooth to aid eruption $365
Apicoectomy Anterior $465 Alveoplasty in conjuction with
Apicoectomy Bicuspid first root $570 extractions per quadrant $290
Apicoectomy Molar first root $665 Alveoplasty not in conjuction with
Apicoectomy each additional root $345 extractions per quadrant $335
Retorgrade Filling per root $210 Removal of lateral exostosis per site $435
Root Amputation per root $310 Incision and drainage of abscess $185
Hemisection (not including RCT) $330 Frenulectomy $340
Internal bleaching per tooth $310 Excision of hyperplasic tissue – per arch $330
Excision of pericoronal gingiva $155
Non-listed procedures performed by the Specialist are provided to all Members at a ‘courtesy fee’ of 20% off the Specialists usual and customary fee.Fees effective January 1, 2013