| 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).
