| Diagnostic |
Bitewing X-rays
| No charge |
Full mouth X-rays
| No charge |
Oral Examinations
| No charge |
| Preventive |
Prophylaxis: adult
| No charge |
Prophylaxis: child
| No charge |
Topical Fluoride: child
| No charge |
| Restorative |
Fillings: amalgams and composites
|
Member's copayment $16 |
Stainless steel crowns
|
Member's copayment $20 |
| Endodontics |
Pulp cap
| No charge |
Pulpotomy
|
Member's copayment $10 |
Root canal: 1 canal
|
Member's copayment $120 |
Root canal: 2 canals
|
Member's copayment $140 |
Root canal: 3 canals
|
Member's copayment $160 |
| Periodontics |
Gingivectomy: per quadrant - Six month waiting per
|
Member's copayment $100 |
Gingivectomy: per tooth - Six month waiting period
|
Member's copayment $16 |
Osseous surgery: per quadrant - Six month waiting
|
Member's copayment $240 |
Scaling/root planning:
per quadrant
|
Member's copayment $34 |
| Oral Surgery |
Impaction: full bony
|
Member's copayment $85 |
Impaction: partial bony
|
Member's copayment $75 |
Impaction: soft tissue
|
Member's copayment $55 |
Single extraction
|
Member's copayment $20 |
Prosthodontics
Dentures, crowns and bridges - Six month waiting period - Member is responsible for the cost of precious metals, if applicable |
Complete denture
|
Member's copayment $280 |
Crowns
|
Member's copayment $190 |
Denture reline: chair
side
|
Member's copayment $40 |
Denture: broken tooth repair
|
Member's copayment $25 |
Partial denture
|
Member's copayment $320 |
Post/core prefabrication
|
Member's copayment $40 |
Orthodontics
24 months of usual and customary orthodontic care, exclusive of records/retention fees |
|
Member's copayment: Adult $1,850/Child
$1,450 |
| Other Services |
Local anesthesia
| No charge |
Office visit: after hours
|
Member's copayment $45 |
Out-of-area emergency care - Maximum payment: $50
|
Member's copayment is all charges
over $50 including applicable copays |
