| All Office Visits |
Participating Dental Office Only
| $5 each visit |
Participating Specialty Offices
| n/a |
Endodontics
Root canal: anterior (excluding final restoration) |
Participating Dental Office Only
| $289 |
Participating Specialty Offices
| $404 |
Endodontics
Root canal: bicuspid (excluding final restoration) |
Participating Dental Office Only
| $341 |
Participating Specialty Offices
| $460 |
Endodontics
Root canal: molar (excluding final restoration) |
Participating Dental Office Only
| $459 |
Participating Specialty Offices
| $566 |
Endodontics
Pulpotomy |
Participating Dental Office Only
| $62 |
Participating Specialty Offices
| $85 |
Periodontics
Gingivectomy: per tooth |
Participating Dental Office Only
| $72 |
Participating Specialty Offices
| $114 |
Periodontics
Gingivectomy: per quadrant |
Participating Dental Office Only
| $194 |
Participating Specialty Offices
| $380 |
Periodontics
Scaling/root planing: per quadrant |
Participating Dental Office Only
| $101 |
Participating Specialty Offices
| $135 |
Periodontics
Osseous surgery: per quadrant |
Participating Dental Office Only
| $520 |
Participating Specialty Offices
| $735 |
Oral Surgery
Single extraction |
Participating Dental Office Only
| $60 |
Participating Specialty Offices
| $79 |
Oral Surgery
Impaction: soft tissue |
Participating Dental Office Only
| $136 |
Participating Specialty Offices
| $161 |
| Diagnostic: Oral examinations |
Participating Dental Office Only
| No charge |
Participating Specialty Offices
| $30 |
Oral Surgery
Impaction: partial bony |
Participating Dental Office Only
| $176 |
Participating Specialty Offices
| $197 |
Oral Surgery
Impaction: full bony |
Participating Dental Office Only
| $200 |
Participating Specialty Offices
| $231 |
Prosthodontics
Crown: porcelain fused to high noble metal |
Participating Dental Office Only
| $432 |
Participating Specialty Offices
| $486 |
Prosthodontics
Post/core prefabrication |
Participating Dental Office Only
| $121 |
Participating Specialty Offices
| $164 |
Prosthodontics
Complete denture |
Participating Dental Office Only
| $577 |
Participating Specialty Offices
| $721 |
Prosthodontics
Partial denture |
Participating Dental Office Only
| $430 |
Participating Specialty Offices
| $766 |
Prosthodontics
Denture reline: chair side |
Participating Dental Office Only
| $103 |
Participating Specialty Offices
| $182 |
Prosthodontics
Partial Denture: broken tooth repair |
Participating Dental Office Only
| $64 |
Participating Specialty Offices
| $95 |
Other Services
Out-of-area emergency care, maximum payment: $50 |
Participating Dental Office Only
| All charges over $50 including
applicable copay(s) |
Participating Specialty Offices
| All charges over $50 including
applicable copay(s) |
Other Services
Office visit: after hours |
Participating Dental Office Only
| $56 |
Participating Specialty Offices
| $56 |
| Diagnostic: X-rays |
Participating Dental Office Only
| No charge |
Participating Specialty Offices
| Vary by procedure |
Other Services
Local anesthesia |
Participating Specialty
Offices
| $14 |
Participating Dental Office Only
| $14 |
Orthodontics
24 months of usual and customary orthodontic care, exclusive of records fees |
Participating Orthodontist
| Adult (age 18 and over) $3,045;
Child (through age 17) $2,870;
Retention $210 |
Preventive
Prophylaxis: adult |
Participating Dental Office Only
| No charge** |
Participating Specialty Offices
| $50 |
Preventive
Prophylaxis: child |
Participating Dental Office Only
| No charge** |
Participating Specialty Offices
| $44 |
Preventive
Topical Fluoride: child |
Participating Dental Office Only
| No charge |
Participating Specialty Offices
| $24 |
Restorative
Fillings: amalgams and anterior composites |
Participating Dental Office Only
| No charge |
Participating Specialty Offices
| Vary by procedure |
Restorative
Stainless steel crowns: primary teeth |
Participating Dental Office Only
| $106 |
Participating Specialty Offices
| $136 |
Endodontics
Pulp cap: direct |
Participating Dental Office Only
| $32 |
Participating Specialty Offices
| $47 |
Dental
Select HMO (ZE70) 
