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Plan 101 AVIA SCHEDULE OF DENTAL SERVICES | Effective January 15, 2021 | THIS IS NOT AN INSURANCE PLAN | All procedures performed by General Dentists.


Procedure

National Average Fee

Avia Members Pay

DIAGNOSTIC
Periodic Oral Exam- Established Patient $65.00 $15.00
Limited Oral Exam-Problem focused $90.00 $20.00
Comprehensive Oral Exam- New or established patient $103.00 $21.00
Full Mouth X-rays Intraoral-complete series, including bitewing $166.00 $45.00
Intraoral-periapical-first film $36.00 $12.00
Intraoral-periapical-each additional film $30.00 $7.00
Bitewing X-ray (single film) $36.00 $12.00
Bitewing X-rays-two films $56.00 $15.00
Bitewing X-rays-three films $67.00 $20.00
Bitewing X-rays-four films $80.00 $24.00
Panoramic X-ray $141.00 $45.00
PREVENTIVE
Prophylaxis-Adult Cleaning (includes scaling and polishing) $114.00 $33.00
Prophylaxis Child Cleaning (includes scaling & polishing) $85.00 $25.00
Sealant- per tooth $65.00 $23.00
Space maintainer-fixed, unilateral-per quad $380.00 $115.00
Space maintainer-fixed-bilateral, maxillary $506.00 $170.00
Space maintainer-removeable-unilateral-per quad $454.00 $132.00
Space maintainer-removable-bilateral, maxillary $557.00 $175.00
RESTORATIVE
Amalgam-one surface, primary or permanent $170.00 $45.00
Amalgam-two surfaces, primary or permanent $211.00 $58.00
Amalgam-three surfaces, primary or permanent $253.00 $68.00
Amalgam-four or more surfaces, primary or permanent $299.00 $80.00
Resin-based composite-one surface. anterior $200.00 $58.00
Resin-based composite-two surfaces, anterior $245.00 $68.00
Resin -based composite-three surfaces, anterior $295.00 $80.00
Resin-based composite- four or more surfaces-anterior $360.00 $104.00
Resin-based composite-one surface-posterior $219.00 $72.00
Resin- based composite-two surfaces-posterior $278.00 $100.00
Resin- based composite-three surfaces-posterior $341.00 $115.00
Resin- based composite-four or more surfaces-posterior $400.00 $145.00
Crown-resin with high noble metal $1,293.00 $460.00
Crown-porcelain fused to high noble metal $1,367.00 $525.00
Crown-porcelain fused to predominantly base metal $1,254.00 $475.00
Crown-porcelain fused to noble metal $1,300.00 $490.00
Crown-full cast high noble metal $1,410.00 $525.00
Recement Crown $135.00 $40.00
Crown-prefabricated stainless steel, primary $329.00 $99.00
Crown-prefabricated stainless steel, permanent $388.00 $114.00
Protective restoration $150.00 $41.00
Core buildup, including pins $325.00 $99.00
Post and core, in addition to crown, indirectly fabricated $475.00 $160.00
Prefabricated post and core in addition to crown $399.00 $125.00
ENDODONTICS
Pulp cap-direct (excluding final restoration) $100.00 $25.00
Pulp cap-indirect(excluding final restoration) $99.00 $25.00
Therapeutic pulpotomy (excluding final restoration) $243.00 $58.00
Anterior Root Canal (excluding final restoration) $902.00 $310.00
Premolar Root Canal (excluding final restoration) $1,045.00 $370.00
Molar Root Canal (excluding final restoration) $1,257.00 $460.00
PERIODONTICS
Gingivectomy or gingivoplasty-per quad $742.00 $300.00
Osseous surgery (including flap & closure) per quad $1,400.00 $510.00
Periodontal scaling & Root planing-per quad $303.00 $105.00
Periodontal maintenance $170.00 $70.00
PROSTHODONTICS
Complete denture-Maxillary $2,009.00 $675.00
Complete denture Mandibular $2,000.00 $675.00
Immediate Denture-Maxillary $2,158.00 $705.00
Immediate denture- Mandibular $2,158.00 $705.00
Partial denture-Maxillary-resin base $1,700.00 $610.00
Partial denture -Mandibular- resin base $1,725.00 $610.00
Partial denture-Maxillary-cast metal framework with resin denture base $2,125.00 $745.00
Partial denture-Mandibular-cast metal framework with resin denture base $2,125.00 $745.00
(all of the above includes retentive/clasps, rests and teeth)
Adjust complete denture-Maxillary $114.00 $36.00
Adjust complete denture-Mandibular $114.00 $36.00
Replace missing or broken teeth (each tooth) $235.00 $55.00
Add tooth to existing partial denture $282.00 $60.00
Add clasp to existing partial denture $320.00 $74.00
Reline complete Maxillary denture (chairside) $435.00 $135.00
Reline complete Mandibular denture (chairside) $435.00 $135.00
Reline partial Maxillary denture (chairside) $420.00 $130.00
Reline partial Mandibular denture (chairside) $425.00 $130.00
Reline complete Maxillary denture (lab) $540.00 $180.00
Reline complete Mandibular denture (lab) $540.00 $180.00
Reline partial Maxillary denture (lab) $535.00 $175.00
Reline partial Mandibular denture (lab) $539.00 $175.00
Pontic-cast high noble metal $1,323.00 $475.00
Pontic-porcelain fused to high noble metal $1,350.00 $475.00
Pontic-porcelain fused to predominantly base metal $1,236.00 $435.00
Retainer Crown-porcelain fused to high noble metal $1,350.00 $505.00
Retainer Crown-porcelain fused to predominantly base metal $1,225.00 $450.00
Crown-full cast high noble metal $1,333.00 $500.00
ORAL AND MAXILLOFACIAL SURGERY
Extraction- erupted tooth or exposed root $225.00 $58.00
Extraction, erupted tooth, requiring removal of bone $338.00 $122.00
Removal of impacted tooth, soft tissue $390.00 $125.00
Removal of impacted tooth, partially bony $477.00 $155.00
Removal of impacted tooth, completely bony $578.00 $225.00
Surgical Removal of residual tooth roots (cutting procedure) $363.00 $122.00
Alveolplasty- in conjunction with extractions (per quad) $360.00 $102.00
Alveolplasty- not in conjunction with extractions (per quad) $517.00 $145.00
Incision and drainage of abscess-Intraoral soft tissue $296.00 $72.00
ORTHODONTICS
Comprehensive Orthodontic treatment of the transitional dentition $5,993.00 25% off normal fees
Comprehensive Orthodontic treatment of the adolescent dentition $5,900.00 25% off normal fees
Comprehensive Orthodontic treatment of the adult dentition $5,995.00 25% off normal fees
GENERAL
Pallative (emergency) treatment $161.00 $40.00
Local Anesthesia $65.00 $14.00
Analgesia-Nitrous oxide $92.00 $25.00
*These National Average Fees are based on the 80th percentile of the survey of dental fees for 2020. 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