MEMBERSHIP

CUSTOMARY

VISITS; EXAMINATIONS; DIAGNOSIS

Initial office visit (one per year) . . . . . . . . . . .. . .. . . . . . . . .. . . . . . . . . . . . . . . . . . . . N/C $50.00

Office visit . . . . . . . . . .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .N/C $50.00

(including observation of patient, when no other services are being provided).

Emergency examination regular hours. . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . N/C $50.00

Special Consultation . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . $40.00 $60.00

(by specialist/ case presentation when diagnostic procedures have been performed by the general dentist)

Prophylaxis treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $69.00 $95.00

Emergency Treatment Palliative (per visit) . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .. . . . . . $50.00 $98.00

Necessary and Diagnostics x-rays . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . N/C $72.00

Panoramic x-ray . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . N/C $59.00

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BASIC RESTORTATIVE DENSTISTRY

Composite Fillings Anteriors

One surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $115.00 $150.00

Two surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $145.00 $190.00

Three or more surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $175.00 $230.00

Composite Fillings Posteriors

One surface .. . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $125.00 $160.00

Two surface. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $165.00 $200.00

Three surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $185.00 $240.00

Sedative Base . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . $35.00 $45.00

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PROSTHETICS

CROWNS

All-Porcelain . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$399.00 $750.00

All-Porcelain over implant . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . $499.0 $850.00

Full or 3/4 CAST METAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $450.00 $620.00

Build up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$125.00 $185.00

Post core and build up; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00 $200.00

Cast post with core or coping (endodontically treated tooth). . . . . . . . . . . . . . . . . . . . $250.00 $320.00

Bridge pontic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$399.00 $750.00

RECEMENTATION

Inlay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $29.00 $49.00

Crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $29.00 $49.00

Bridges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $39.00 $69.00

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ORAL SURGERY

We expect that all surgeries to be performed in one of our offices. If at any time treating Doctor feels that the
patient needs to be treated in a hospital setting, then all hospital costs including transportation and ambulatory
services are the sole responsibility of the patient. Additional fees charged by the dentist for the performing
procedures in the hospital are also the responsibility of the patient.

EXTRACTIONS

Uncomplicated single . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$100.00 $185.00

Surgical removal of an erupted tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00 $220.00

Post operative visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .N/C $100.00

Frenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$100.00 $328.00

Alveolectomy per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100.00 $180.00

Local Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .N/C $25.00

Sedation with Oral Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00 $250.00

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IMPLANTS

Implant Complete (post, abutment, crown). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$1299.00 $2700.00

Implant only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$1000.00 $1400.00

Surgical removal of an erupted tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00 $220.00

Post operative visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C $100.00

Frenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .N/C $328.00

Alveolectomy per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .N/C $180.00

Local Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .N/C $25.00

Sedation for implant surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C $250.00

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PERIODONTICS

Emergency treatment

(periodontal abscess, acute periodontitis, etc.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $55.00 $98.00

Subgingival curettage and root planning per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . .$85.00 $145.00

ENDODONTIC

Vital Pulpotomy (in addition to restoration) per treatment . . . . . . . . . . . . . . . . . . . . . . $55.00 $100.00

Pulp capping (recalcification) including

ROOT CANAL THERAPY

Anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $335.00 $400.00

Bicuspid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $390.00 $510.00

Apical surgery including filling of the root canal and / or

retrograde therapy single operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$450.00 $618.00

Apicoectomy (separate procedure) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $330.00 $330.00

DENTURES

(Fee for specialized technique involving precision denture, personalized or characterization must be paid by patient.)

Cosmetic Dentures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$750.00 $950.00

Complete upper denture, acrylic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $530.00 $750.00

Complete lower denture, acrylic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $530.00 $750.00

Partial acrylic upper or lower, cast metal clasps

base( two clasps at N/C) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $515.00 $921.00

Partial acrylic upper or lower with chrome cobalt alloy partial or lingual bar and

acrylic saddles-base (with two clasps at N/C) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $555.00 $950.00

Teeth and Clasp extra per unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $29.00 $35.00

Anterior stayplate (temporary) base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00 $350.00

Denture adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30.00 $55.00

Denture reline (laboratory) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $170.00 $270.00

NOTE: In some of the following instances proper treatment will require a procedure combined with a procedure for which no deception is
listed. In these instances members, must be advised in advance of treatment of the maximum charge and the co-payment required which may
not exceed 80% of the providing dentist usual and customary fee.

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SUMMARY OF EXCLUSIONS AND LIMITATIONS

The following is a summary of exclusions and limitations applicable to your preventive

dental maintenance plan:

The correction of congenital abnormalities.

Oral surgery requiring the setting of fractures or dislocation of the jaw.

Treatment of Malignancies.

Dispensing of drugs not normally supplied in a dental practice.

General anesthetic and/or surgical extraction of wisdom teeth unless specifically included in coverage.

Dental services of any nature performed in a hospital or other outside facility. The Cost of any hospitalization shall
be borne by the patient.

Services to which the member is entitled under any Worker’s Compensation Law Act. The plan shall provide the
services at the time of need, but the member shall execute and deliver such documents or take such actions as may
be necessary to assure the plan is reimbursed for the benefits provided by Worker’s Compensation.

Charges of Broken Appointments

Completion of treatment initiated by any dentist prior to the patients effective date of benefits.

Fees for any necessary referred specialists services, such as oral surgery or speech therapy.