*Partial list of co-pay services...over 300 services covered.

Dental Treatment

Your Cost

Average Retail Cost

 Appointment

    Periodic Oral Exam

No Charge

$31

    Limited Oral Exam

$25

$53

    Comprehensive Oral
            Exam

No Charge

$56

Diagnostic

    Complete X-Ray Series,
            Including Bitewings

$5

$85

Preventative Dentistry

    Routine Cleaning - Adult
    (once every 6 months)

$5

$64

    Routine Cleaning - Child
    (Once every 6 months)

$5

$44

    Application of Flouride
    (up to 18 years of age)

No Charge

$21

    Oral Hygiene Instruction

No Charge

$30

    Application of Sealant
          Per Tooth,

$15

$34

    Fixed Space Maintainer

$70

$289

Fillings/Crowns

    Silver Fillings

       One Surface

$20

$85

       Two Surfaces

$25

$106

       Three Surfaces

$50

$133

    White Fillings

        One Surface, Anterior

$45

$104

        Two Surfaces, Anterior

$55

$126

        Three Surfaces, Anterior

$73

$159

        One Surface, Posterior

$80

$113

        Two Surfaces, Posterior

$90

$143

        Three Surfaces, Posterior

$100

$187

        Crowns - Porcelain in High
              Noble Metal 

$280

$756

        Core Build-up

$85

$169

Root Canals

     Anterior

$155

$532

     Bicuspid

$225

$612

     Molar

$279

$791

Periodontics

     Periodontic Scaling and
      Root Planing Per quadrant

$55

$170

     Full Mouth Debridement
     complicated cleaning)

$85

$95

    Dentures

    Compete Denture - Upper

$325

$884

    Complete Denture - Lower

$410

$884

    Partial Denture - Upper

$390

$664

    Partial Denture - Lower

$390

$541

Oral Surgery

    Single Tooth Extraction

$30

$88

    Removal of Impacted Tooth

    Soft Tissue Extraction

$30

$88

    Removal of Impacted Tooth

$75

$228

       Soft Tissue

$75

$228

       Partial Bony

$100

$296

       Complete Bony

$140

$315

       Complete Bony with
            Complications

$170

$346

Orthodontics

Orthodontic treatment for children and adults is provided at a 25% reduction from the Plan Specialists normal retail charges.