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Schedule Revised 01/05

  Approximate**
General Dentist Charge 90 percentile - 2004
OHC**
Member Cost MAXI-DENT PLUS
OHC**
Member Potential Savings
Plan**
Approximate
% Coverage
Basic Preventative & Diagnostic Benefits*
Initial Exam (limited) (Doctor may charge extra for comprehensive oral exam)
$42.00
No Charge
$42.00
100%
Bite Wing X-rays (2)
$37.00
No Charge
$37.00
100%
Fluoride Treatment
$34.00
No Charge
$34.00
100%
Cleaning (Prophylaxis) Adult
$79.00
`No Charge
$79.00
100%
Full Set of X-rays (including Bitewings)
$106.00
No Charge
$106.00
100%
Total
$298.00
$0.00
$298.00
100%
 
(Check-ups
twice a year)
 
Regular Restoration Dentistry*
Fillings (Amalgam)
Single Surface
$110.00
$27.00
$83.00
76%
Two Surface
$143.00
$31.00
$112.00
78%
Three Surface
$175.00
$47.00
$128.00
73%
         
Oral Surgery*        
Simple Extraction
$135.00
$31.00
$104.00
77%
Wisdom Tooth Extraction - Soft Tissue
$273.00
$61.00
$212.00
78%
 
Special Restoration Dentistry*
Full Cast Crown*
$825.00
$335.00
$490.00
59%
Porcelain & metal crown
$937.00
$383.00
$545.00
59%
 
Endodontics*
Single root canal
$600.00
$163.00
$437.00
73%
Two root canals
$696.00
$215.00
$481.00
69%
Three root canals
$850.00
$329.00
$521.00
62%
 
Periodontics*
Tooth scaling and root planning
(per quadrant)
$215.00
$90.00
$125.00
58%
Subgingval curettage - gums
(per quadrant)
$287.00
$90.00
$197.00
69%
Equilibration-bite adjustment (Major)
$610.00
$211.00
$399.00
65%
 
Prosthodontics*
Denture (no extractions)
$1424.00
$423.00
$1001.00
70%
Partial Denture
$1500.00
$524.00
$976.00
65%
 
Orthodontics* (70 percentile) Adolescent
$4363.00
$3272.00
$1090.00
**25%
         
         

The Best Plan covers Diagnostic Consultation, Preventive Consultation, T.M.J. Consultation, Sealants, Direct Pulp Capping, Pulpectomy, Apexification, T.M.J. Appliance & Bonding of facings, which the medium plan Maxi-Dent does not cover. *This is a partial schedule of benefits, please see exhibits and disclaimers. **All figures and procedures are an estimation and approximation.

 

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