| Services Covered in Full |
| Procedure | Patient Co-Pay |
| Comprehensive Oral Exams | No Charge |
| Periodic Oral Exams | No Charge |
| Limited Oral Exams | No Charge |
| Complete Series X-rays | No Charge |
| Periapical - Single Film | No Charge |
| Additional Film | No Charge |
| Occlusal Film | No Charge |
| Bitewing - Single Film | No Charge |
| Bitewings - Two Films | No Charge |
| Bitewings - Four Films | No Charge |
| Panoramic | No Charge |
| Prophylaxis - Adult | No Charge |
| Prophylaxis - Child | No Charge |
| Amalgam, One Surface * | No Charge |
| Amalgam, Two Surfaces * | No Charge |
| Amalgam, Three Surfaces * | No Charge |
| Amalgam, Four Surfaces * | No Charge |
| Anterior Composite - One Surface * | No Charge |
| Anterior Composite - Two Surfaces * | No Charge |
| Anterior Composite - Three Surfaces * | No Charge |
| Anterior Composite - Incisal/Four * | No Charge |
| Recement Inlay * | No Charge |
| Recement Crown * | No Charge |
| Direct/Indirect Pulp Cap * | No Charge |
| Pulpotomy * | No Charge |
| Root Canal - Anterior * | No Charge |
| Recement Bridge * | No Charge |
| Routine Extraction * | No Charge |
| Coronal Extraction - Primary * | No Charge |
| |
| Services with Patient Co-Pays |
| Diagnostic & Preventive Services |
Patient Co-Pays |
| Cephalometric Film | 50.00 |
| Diagnostic Models | 37.00 |
| Topical Acid Fluoride | 31.00 |
| Sealants | 30.00 |
| Space Maintainer - Fixed - Unilat. | 156.00 |
| Space Maintainers - Fixed - Bilat. | 220.00 |
| Space Maintainer - Removable | 188.00 |
| |
|
| Restorative Dentistry | |
| Pin Retention | 25.00 |
| Gold Inlay - Two Surface | 300.00 |
| Gold Inlay - Three Surface | 360.00 |
| Onlay - Additional | 62.00 |
| Porcelain Inlay | 220.00 |
| Porcelain Laminate - Lab | 395.00 |
| Resin Crown | 200.00 |
| Resin/Noble Metal Crown | 425.00 |
| Resin/High Noble Crown | 525.00 |
| Porcelain Crown | 425.00 |
| Porcelain/Noble Metal Crown | 525.00 |
| Porcelain/High Noble Crown | 595.00 |
| Full Cast Noble Metal Crown | 425.00 |
| Full Cast High Nobel Crown | 525.00 |
| ¾ Cast Crown | 310.00 |
| Stainless Steel Crown | 110.00 |
| Build-up with Pins - Core | 100.00 |
| Cast Post | 165.00 |
| Post | 105.00 |
| |
| Endodontics | |
| Root Canal - Bicuspid | 425.00 |
| Root Canal - Molar | 500.00 |
| Apicoectomy - Anterior | 210.00 |
| Apicoectomy - Molar | 235.00 |
| Apicoectomy - Each Additional Root | 125.00 |
| Retrograde - Amalgam Per Root | 55.00 |
| Root Amputation - Per Root | 150.00 |
| Hemi Section | 150.00 |
| |
|
| Periodontics | |
| Gingivectomy, Per Tooth | 42.50 |
| Gingivectomy, Per Quad | 180.00 |
| Gingival Flap Curettage Quad | 275.00 |
| Osseous Surgery, Per Quad | 460.00 |
| Osseous Graft, Single | 175.00 |
| Soft Tissue Graft, Pedicle | 130.00 |
| Free Gingival Graft | 275.00 |
| Periodontal Scaling, Quad | 90.00 |
| Periodontal Maintenance | 72.50 |
| |
| Prothetics - Removable | |
| Full Upper/Lower Denture | 650.00 |
| Immediate Upper/Lower Denture | 675.00 |
| Partial Upper/Lower - Acrylic w/ Clasps | 450.00 |
| Partial Upper Cast w/ Pal Bar | 695.00 |
| Partial Lower Cast w/ LG Bar | 695.00 |
| Denture Adjustments | 25.00 |
| Repair Broken Denture | 65.00 |
| Repair Framework | 100.00 |
| Replace Broken Clasp - Intact | 90.00 |
| Replace Broken Tooth | 55.00 |
| Rebase - Complete Upper Denture | 250.00 |
| Reline Full Denture - Chair | 135.00 |
| Reline Partial Denture - Chair | 90.00 - 135.00 |
| Reline Full Denture - Lab | 150.00 - 200.00 |
| Reline Partial Denture - Lab | 145.00 - 180.00 |
| Tissue Conditioning | 62.00 |
| |
| Prosthetics Fixed | |
| Cast Noble Metal Pontic | 425.00 |
| Porcelain/Noble Metal Pontic | 525.00 |
| Resin/Noble Metal Pontic | 425.00 |
| Cast High Noble Pontic | 525.00 |
| Porcelain/High Noble Pontic | 595.00 |
| Resin/High Noble Pontic | 525.00 |
| Resin Bonded Retainers | 225.00 |
| Resin/High Noble Abutment | 525.00 |
| Resin/Noble Metal Abutment | 425.00 |
| Porcelain/Noble Metal Abutment | 525.00 |
| Porcelain/High Noble Abutment | 595.00 |
| Cast High Noble Abutment | 525.00 |
| ¾ Cast Abutment | 310.00 |
| Cast Noble Metal Abutment | 425.00 |
| |
| Oral Surgery | |
| Surgical Extraction | 110.00 |
| Impaction - Soft Tissue | 155.00 |
| Impaction - Partial Bony | 188.00 |
| Impaction - Full Bony | 240.00 |
| Impaction - Full w/Sectioning | 275.00 |
| Surgical Removal Roots | 90.00 |
| Closure of Oral Antral Fistula | 395.00 |
| Tooth Re-Implantation | 120.00 |
| Surgical Exposure | 225.00 |
| Biopsy - Hard Tissue | 90.00 |
| Biopsy - Soft Tissue | 75.00 |
| Alveoloplasty w/ Extraction, Quad | 62.00 |
| Alveoloplasty w/out Extraction, Quad | 125.00 |
| |
| Orthodontics | |
| Habit Appliance - Removable | 375.00 |
| Habit Appliance - Fixed | 395.00 |
| Ortho - Initial Insertion | 750.00 |
| Ortho - Periodic Visit 24 | 90.00 |
| |
| Adjunctive General Services | |
| Palliative Treatment | 30.00 |
| General Anesthesia, 30 Minutes | 115.00 |
| General Anesthesia, additional 15 min | 55.00 |
| Consultation | 50.00 |
| Occlusal Adjustment - Limited | 55.00 |
| Occlusal Adjustment - Complete | 150.00 |
| Bleaching of Discolored Tooth | 150.00 |
The following limitations apply to all Dentcare dental plans:
Oral exams, bitewing x-rays, prophylaxes, scalings and fluoride treatments - Once every six months.
Full mouth and panoramic x-rays - Once every 36 months
Under family coverage, children are covered to age 19 (23 if full time students).
