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Select HMO (ZE7N) Select Another Plan Determine the rates for the medical plan you selected and other available plans by clicking on the Get a Personalized Quote link on the left. Office Visit Office Visit $5 Diagnostic 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)-chair side $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 tooth or exposed 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 co payments 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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