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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.
© Copyright, 2005, Oral Health Care, Inc. All rights reserved.