Prepaid Group Dental Plan
Plan
A
Procedure
Patient Cost
Diagnostic
Charting history, oral examination, periodic recall
examination (every six months), emergency
treatment No
Charge
Radiographic
Complete intraoral
series, periapical and
bitewing films
No Charge
Intraoral
periapical
No Charge
Each additional single film (periapical
or
bitewing)
No Charge
Occlusal
view
x-ray
No Charge
Lateral jaw x-ray,
each
No Charge
Four bitewing x-ray
films
No Charge
Antero-posterior
x-ray of head and
jaw
No Charge
Cephalometric
radiograph
No Charge
Panoramic (panography)
including
bitewings
No Charge
Preventive
Oral prophylaxis (every six
months)
No Charge
Topical fluoride treatment following
prophylaxis
No Charge
Space maintainers
– unilateral $ 5.00
Space maintainers –
bilateral
$ 10.00
Operative
(Restorative) Services
Primary Silver amalgam – 1
surface
No Charge
Primary Silver amalgam – 2
surfaces
No Charge
Primary Silver amalgam – 3 surfaces or
more
No Charge
Permanent Silver amalgam – 1
surface
No Charge
Permanent Silver amalgam – 2
surfaces
No Charge
Permanent Silver amalgam – 3 surfaces or
more No
Charge
Silver amalgam reinforcement pins – 1st
No Charge
Each additional
pin
No Charge
Composite filling (for front
teeth)
No Charge
Composite Class
III
No Charge
Composite Class
IV
No Charge
Core
build-up (including any
pins)
$ 15.00
Periodontia
Root scaling and root planing (per
quadrant)
$ 50.00
Prophylaxis, medication and minor bite
correction
$ 20.00
Gingivectomy,
Gingivoplasty (per
quadrant)
$ 120.00
Occlusal
adjustment (and/or
equilibration)
$ 10.00
Bite
guard
$ 25.00
Osseous surgery (per
quadrant)
$ 140.00
Endodontics
(including radiographs)
Single root canal,
filling
$ 50.00
Double root canal,
filling
$ 85.00
Triple or more root canal,
filling
$ 125.00
Apicoectomy
(per
root)
$ 55.00
Simple Extractions (including Local anesthesia)
Single
tooth
$ 10.00
Each additional
tooth
$ 10.00
Oral Surgery Extractions (including Local
anesthesia)
Surgical
extraction
$ 20.00
Extraction of tooth (soft tissue
impaction)
$ 50.00
Extraction of tooth (partial bony
impaction)
$ 75.00
Extraction of tooth (complete bony
impaction)
$ 90.00
Alveoplasty/Alveolectomy
(per jaw maximum) per quadrant in
conjunction with
extraction
$ 55.00
Alveoplasty, including
ridge extension,
arch
No Charge
Excision of benign tumor, lesion diameter up to 2.5
cm $ 15.00
Removal of cyst up to 2.5 cm
diameter
$ 50.00
Prosthetics (including adjustments and relines for 6
months
following installation) removable
Full upper
denture
$ 175.00
Full lower
denture
$ 175.00
Partial upper or lower denture without clasps,
acrylic base $ 150.00
Partial upper or lower denture with two chrome
clasps with
rests, acrylic
base
$ 175.00
Partial upper or lower with chrome lingual or
palatal bar with
two clasps and rests, acrylic
base
$ 175.00
Repair
broken full or partial denture, no teeth
damaged No Charge
Repair
broken full or partial denture, replace broken
tooth $ 10.00
Each additional
tooth
$ 10.00
Replace broken tooth on denture, no other
repairs
$ 10.00
Each additional
tooth
$ 10.00
Adding tooth to partial denture to replace extracted
tooth $ 20.00
Each additional
tooth
$ 20.00
Reattaching clasp on denture, clasp
intact
$ 35.00
Replacing broken clasp with new clasp on
denture
$ 55.00
Relining upper or lower full or partial denture
(office)
once every three
years
$ 20.00
Relining upper or lower full or partial denture
(lab)
once every three
years
$ 35.00
Jump case, complete denture (duplicate of denture)
once every three
years
$ 90.00
Crowns
Two surface gold
inlay
$ 175.00
Three or more surfaces gold
inlay
$ 175.00
Acrylic
jacket
No Charge
Acrylic with metal
(semi-precious)
$ 150.00
Porcelain
jacket
$ 175.00
Porcelain fused to metal
(semi-precious)
$ 175.00
¾
cast
$ 150.00
Full
cast
$ 150.00
Bridges – Pontics &
Abutments (fixed)*
Cast
$ 150.00 each
Maryland
bridge
$ 175.00 each
Porcelain fused to metal
(semi-precious)
$ 175.00 each
Plastic processed to metal
(semi-precious)
$ 175.00 each
Orthodontic
Maximum, 24 months (to age
19)
$ 1,300.00
Adult
(19 years or
older)
$ 2,500.00
