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Plan 101 AVIA SCHEDULE OF DENTAL SERVICES | Effective January 1, 2015 | THIS IS NOT AN INSURANCE PLAN | All procedures performed by General Dentists.


Procedure

National Average Fee

Avia Members Pay

DIAGNOSTIC
Periodic Oral Exam $57.00 $15.00
Limited Oral Exam-problem focused $85.00 $17.00
Comprehensive Oral Exam $100.00 $18.00
Full Mouth X-rays Intraoral-complete series, including bitewing $148.00 $42.00
Intraoral-periapical-first film $33.00 $11.00
Intraoral-periapical-each additional film $28.00 $6.00
Bitewing X-ray (single film) $32.00 $10.00
Bitewing X-rays-two films $50.00 $14.00
Bitewing X-rays-three films $61.00 $18.00
Bitewing X-rays-four films $73.00 $21.00
Panoramic X-ray $126.00 $40.00
Diagnostic casts $132.00 $35.00
PREVENTIVE    
Prophy-Adult Cleaning (includes scaling and polishing) $103.00 $30.00
Prophy- Child Cleaning (includes scaling & polishing) $75.00 $22.00
Fluoride Treatment $43.00 $18.00
Oral hygiene instructions $61.00 $8.00
Sealant- per tooth $63.00 $20.00
SPACE MAINTENANCE    
Space maintainer-fixed-unilateral $350.00 $110.00
Space maintainer-fixed-bilateral $473.00 $150.00
Space maintainer-removeable-unilateral $424.00 $122.00
Space maintainer-removeable-bilateral $527.00 $155.00
RESTORATIVE    
Amalgam-one surface, primary or permanent $165.00 $42.00
Amalgam-two surface, primary or permanent $210.00 $53.00
Amalgam-three surface, primary or permanent $256.00 $63.00
Amalgam-four or more surfaces, primary or permanent $300.00 $78.00
Resin-one surface-anterior $190.00 $53.00
Resin-two surface-anterior $232.00 $63.00
Resin -three surface-anterior $285.00 $78.00
Resin-four or more surface-anterior $351.00 $98.00
Resin/composite-one surface-posterior $204.00 $68.00
Resin/composite-two surface-posterior $261.00 $85.00
Resin/composite-three surface-posterior $324.00 $99.00
Resin/composite-four or more surface-posterior $394.00 $130.00
Crown-resin with high noble metal $1,221.00 $435.00
Crown-porcelain fused to high noble metal $1,270.00 $495.00
Crown-porcelain fused to predominantly base metal $1,182.00 $445.00
Crown-porcelain fused to noble metal $1,208.00 $455.00
Crown-full cast high noble metal $1,298.00 $475.00
Recement Crown $127.00 $36.00
Crown-prefabricated stainless steel, primary $300.00 $92.00
Crown-prefabricated stainless steel, permanent $360.00 $105.00
Sedative filling $136.00 $36.00
Core buildup, including pins $305.00 $92.00
Cast post and core, in addition to crown $475.00 $148.00
Prefabricated post and core in addition to crown $380.00 $115.00
ENDODONTICS    
Pulp cap-direct (excluding final restoration) $95.00 $22.00
Pulp cap-indirect(excluding final restoration) $94.00 $22.00
Therapeutic pulpotomy (excluding final restoration) $227.00 $53.00
Anterior Root Canal (excluding final restoration) $850.00 $285.00
Bicuspid Root Canal (excluding final restoration) $964.00 $340.00
Molar Root Canal (excluding final restoration) $1,169.00 $420.00
PERIODONTICS    
Gingivectomy or gingivoplasty-per quad $725.00 $275.00
Gingivectomy or gingivoplasty-per tooth $355.00 $90.00
Osseous surgery (including flap entry & closure) per quad $1,237.00 $465.00
Periodontal scaling & Root planing-per quad $285.00 $93.00
Full mouth debridement $202.00 $68.00
Periodontal maintenance procedures $156.00 $62.00
PROSTHODONTICS    
Complete denture-Maxillary $1,969.00 $620.00
Complete denture Mandibular $1,984.00 $620.00
Immediate Denture-Maxillary $2,077.00 $650.00
Immediate denture- Mandibular $2,100.00 $650.00
Partial denture-Maxillary-resin base $1,536.00 $560.00
Partial denture -Mandibular- resin base $1,534.00 $560.00
Partial denture-Maxillary-cast metal framework with resin denture base $2,018.00 $690.00
Partial denture-Mandibular-cast metal framework with resin denture base $2,024.00 $690.00
(all of the above includes conventional clasps, rests and teeth)    
Adjust complete denture-Maxillary $100.00 $32.00
Adjust complete denture-Mandibular $99.00 $32.00
Repair broken complete denture base $246.00 $55.00
Replace missing or broken teeth (each tooth) $217.00 $50.00
Add tooth to existing partial denture $259.00 $55.00
Add clasp to existing partial denture $303.00 $68.00
Reline complete Maxillary denture (chairside) $420.00 $128.00
Reline complete Mandibular denture (chairside) $417.00 $128.00
Reline partial Maxillary denture (chairside) $405.00 $122.00
Reline partial Mandibular denture (chairside) $411.00 $122.00
Reline complete Maxillary denture (lab) $525.00 $170.00
Reline complete Mandibular denture (lab) $525.00 $170.00
Reline partial Maxillary denture (lab) $520.00 $165.00
Reline partial Mandibular denture (lab) $524.00 $165.00
Pontic-cast high noble metal $1,251.00 $440.00
Pontic-porcelain fused to high noble metal $1,250.00 $440.00
Pontic-porcelain fused to predominantly base metal $1,185.00 $405.00
Crown-porcelain fused to high noble metal $1,271.00 $465.00
Crown-porcelain fused to predominantly base metal $1,163.00 $415.00
Crown-full cast high noble metal $1,275.00 $450.00
ORAL AND MAXILLOFACIAL SURGERY    
Extraction- single tooth-erupted tooth or exposed root $200.00 $55.00
Surgical Removal of erupted tooth $310.00 $102.00
Removal of impacted tooth, soft tissue $350.00 $110.00
Removal of impacted tooth, partially bony $439.00 $140.00
Removal of impacted tooth, completely bony $531.00 $202.00
Surgical Removal of residual tooth roots (cutting procedure) $349.00 $109.00
Alveolplasty- in conjunction with extractions (per quad) $336.00 $92.00
Alveolplasty- not in conjunction with extractions (per quad) $500.00 $135.00
Incision and drainage of abscess-Intraoral soft tissue $271.00 $67.00
ORTHODONTICS    
Comprehensive Orthodontic treatment of the transitional dentition $5,622.00 20% off normal fees   
Comprehensive Orthodontic treatment of the adolescent dentition $5,800.00 20% off normal fees   
Comprehensive Orthodontic treatment of the adult dentition $5,841.00 20% off normal fees   
GENERAL    
Pallative (emergency) treatment $145.00 $35.00
Local Anesthesia $85.00 $14.00
Analgesia $90.00 $25.00
Broken appointment (without notice) $50.00 $25.00
*These are typical fees based on the 80th percentile of the National Dental Advisory Service Fee Report for 2014. Member is responsible for all charges at the time of service. This entire fee schedule is for participating Avia Dental General Dentists only. Cosmetic and any other procedures not listed are 25% off the provider’s normal fee. Some fees may vary where unusual services and/ or materials are required. Please discuss all fees with dentist prior to treatment. Lab fees are additional. Fees schedules are subject to change without prior notice to members. Be sure to verify that a dentist is a participating Avia provider before seeking treatment. Avia cannot guarantee the continued participation of any dentist. If dentist leaves plan, you will need to select another participating provider. Any dental procedures performed by a non participating dentist are charged dentist’s normal fees. Not all types of dentists may be available in your area. Avia does not guarantee the quality of service of the providers.
Participating Specialists do not charge according to this fee schedule. Avia Members receiving treatment from any participating specialists including Oral surgeons, Orthodontists, Periodontists, Pediatrics, Pedodontists, Prosthodontists and Endodontists will receive a 25% discount off their normal fees.
THIS IS NOT AN INSURANCE PLAN