| Dental Services |
Patient Pays |
PREVENTATIVE PROCEDURES
Teeth
Cleaning (2 times per year)
X-rays
Examinations
Fluoride Treatments |
$0.00 -You Pay Nothing! |
Periodontal Procedures
Gum Therapy
Deep Cleanings w/anesthesia |
$0.00 -You Pay Nothing! |
Fillings:
Silver Fillings
Composite “Tooth Colored” Fillings |
$0.00 -You Pay Nothing!
Small Out Of Pocket Expense |
Extractions with a General Dentist
Extractions with a Specialist (Oral Surgeon)
|
$0.00 -You Pay Nothing!
25% Courtesy Discount |
| Root Canal Procedures |
$200.00 Pre-set Co-payment |
| Crowns (Caps) |
$150.00 Pre-set Co-payment |
Bridges
(Permanently placed to fill in for
missing teeth) |
$125.00 per number of teeth involved
in bridge |
Partial Dentures
(Removable appliance to fill in for
missing teeth) |
$125.00 Pre-set Co-payment |
Full Dentures
(Removable appliance to replace all
missing teeth) |
$125.00 Pre-set Co-payment |
Orthodontic Procedures (braces)
A standard 2 year case |
$200 Retention PAID AT THE
BEGINNING OF THE CASE, plus:
After the initial down payment you pay only small monthly payments
for a standard two year case.
Above fees do not include specialty brackets or wires.
|
Orthodontic Procedures (braces)
Advanced Case Phase 1 |
$200 Retention PAID AT THE
BEGINNING OF THE CASE, plus:
After the initial down payment you pay only small monthly payments
for a standard two year case.
Since Orthodontic benefits have been exhausted in Phase
1, Phase 2 will be provided at the rate listed below.
Above fees do
not include specialty brackets or wires. |
Orthodontic Procedures (braces)
Advanced Case Phase 2 |
A 25% courtesy discount from the Usual,
Customary and Reasonable Fees (UCR) charged by the dentist, since
your benefits were exhausted in Phase 1.
Above fees do not include specialty brackets or wires. |
