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Utah

UTAH

Resource 1

Non-Member

YOU

Member Fees

Usual/Customary Fees

$AVE

Schedule A

 

 

 

I.  Initial Diagnosis - Treatment Planning & Radiographic Procedures
    A.  Initial Consultation and Comprehensive Oral Exam

- Included -

$225

$225

    B.  Panographic X-Ray

- Included -

$118

$118

II.  Dental Implant Surgery
    A.  Endosseous Implants - Root Form

$1,500

$2,500

$1,200

    B.  Ridge Augmentation - Bone Graft (Partial)

$650

$1,250

$600

    C.  Bone Graft to Correct Site Defects

$475

$875

$400

    D.  Sinus Augmentation (Per Sinus)

$1,850

$3,500

$1,650

    E.  Sinus Lift with Apical Graft

$475

$875

$400

    F.  Extraction - General

$150

$250

$100

    G.  Extraction - Surgical

$225

$350

$125

III.  Dental Implant Prosthetics (Crown & Bridge)
     A.  Porcelain-Metal Implant Crown(s)

 $1,000

 $1,500

 $550

     B.  All Porcelain (Zirconia Base) Implant Crown(s)

 $1,100

 $1,500

 $500

 

 

 

 
IV.  Dental Implant Prosthetics (Overdenture)

 

    A.  O-Ring Overdenture (includes O-Ring Attachments)

$3,200

$5,000

$1,800

    B.  Hader Bar Overdenture w/ Hader Clips (includes Attachments)

$5,500

$6,500

$1,000

    C.  Fixed-Fixed Hybrid Prosthesis - FULL ARCH

$5,500

$10,500

$5,000

 

V.  Cosmetic Dental Services

 

    A.  Porcelain Veneers

$950

$1,350

$400

    B.  InVisalign (Clear Braces)

$4,500

$7,000

$2,500

    C.  Tooth Whitening

$150/per arch

$250/per arch

$100

 

VI.  Implant Maintenance*

 

    A.  Dental Cleaning

$75

$93

$18

    B.  Oral Examination

$30

$50

$20

    C.  Panographic X-Ray

$45

$118

$73

    D.  Dental Cleaning, Oral Examination and Panographic X-Ray

 $150

 $261

$111

* Required 2 (two) per year to maintain 10-year warranty

    Implant hygiene appointments and cleanings must be provided and documented by a Resource 1 Provider.

IMPLANT SURGERY INCLUDES:

  1. Dental Implant Placement
  2. Local Anesthetic
  3. Follow Up Examination(s)

NOTE:  IMPLANT PLACEMENT FEE DOES NOT INCLUDE:

    - IV Sediation

**Anything not defined in the Resource 1 Fee Schedule is the providers U/C fee.

Subject:  PPA-10UTRev