Procedure |
Patient Pays |
|
Procedure |
Patient Pays |
Diagnostic |
|
Crowns/Bridges
All charges for crown and bridge are per unit. There will be an additional charge for the actual cost for gold/high noble metal for the procedures identified by an asterisk. |
Office Visit |
$10.00 |
|
Exam-Periodic** |
No Charge |
|
Exam-Comprehensive** |
No Charge |
|
X-ray, Intraoral, Complete Series (including bitewings)** |
No Charge |
|
Inlay or Onlay, Metallic* |
$220.00 |
X-ray, Intraoral, First Film |
No Charge |
|
Crown, Porcelain/Ceramic Substrate |
$260.00 |
X-ray, Intraoral, Additional |
No Charge |
|
Crown, Porcelain Fused to Metal* |
$260.00 |
X-ray, Intraoral, Occlusal |
No Charge |
|
Crown, Full Casts Metal* |
$260.00 |
X-ray, Extraoral, First Film |
No Charge |
|
Crown, ¾ Casts Metal * |
$250.00 |
X-ray, Extraoral, Additional |
No Charge |
|
Recement Inlays/Crowns |
$15.00 |
X-ray, Bitewing-Single Film ** |
No Charge |
|
Crown, Stainless Steel Primary Tooth (Child) |
$45.00 |
X-ray, Bitewing-Two Films |
No Charge |
|
Crown, Prefab. Stainless Steel Permanent Tooth |
$60.00 |
X-ray, Bitewing-Four Films |
No Charge |
|
Core Build, including pairs |
$45.00 |
X-ray, Panoramic |
No Charge |
|
Cast Post and Core, in add. to Crown |
$80.00 |
Pulp Vitality Test |
No Charge |
|
Prefab. Post and Core, in add. to Crown |
$71.00 |
Diagnostic Casts |
No Charge |
|
Pontic, Full Casts Metal |
$260.00 |
Preventive |
|
Pontic, Porcelain Fused to Metal |
$260.00 |
Prophylaxis-Adult (limit 2 per year) |
No Charge |
|
Crown, Abutment, Porcelain Fused to Metal |
$260.00 |
Prophylaxis-Child (limit 2 per year) |
No Charge |
|
Crown, Abutment, Full Casts Metal* |
$260.00 |
Topical Application of Fluoride (1 per year under age of 16) |
No Charge |
|
Recement Bridge |
$20.00 |
Oral Hygiene Instructions |
No Charge |
|
Add. Charge per Unit for Full Mouth Rehabilitation |
$125.00 |
Sealant-per Tooth (under age 16)** |
$10.00 |
|
Full Mouth rehabilitation is defined as 6 or more units of covered crowns and or pontics under one treatment plan. |
Space Maintainers-Fixed |
$65.00 |
|
Space Maintainers-Removable (includes adjustments within 6 months of installations) |
$80.00 |
|
Endodontics |
Recement Space Maintainers |
$15.00 |
|
Pulp Cap, Direct or Indirect |
No Charge |
Restorative |
|
Therapeutic Pulpotomy |
$35.00 |
PRIMARY TEETH |
|
Root Canal, Anterior |
$120.00 |
Amalagram-1-4 Surfaces or More |
No Charge |
|
Root Canal, Bicuspid |
$140.00 |
PERMANENT TEETH |
|
Root Canal, Molar |
$280.00 |
Amalagram-1-4 or More Surfaces |
No Charge |
|
Apicoectomy/Periradicular Surgery, Anterior |
$130.00 |
Resin-1-4 or More Surfaces or Incisal Angle, Anterior |
No Charge |
|
Apicoectomy/ Periradicular Surgery, Bicuspid- 1st root |
$130.00 |
Sedative Filling |
$8.00 |
|
Apicoectomy/ Periradicular Surgery, Molar – 1st Root |
$150.00 |
Pin Retention, exclusive of Restoration |
$6.00 |
|
Apicoectomy/ Periradicular Surgery Each Additional Root |
$90.00 |
