Yearly Enrollment Contract

Preventative Cleaning (Adult) – 1st visit @ Rivertowne Dental


Comprehensive Exam, Prophylaxis (cleaning), 4 Bitewing and Panorex X-rays are FREE

(Cost without discount plan $556)

Preventative Cleaning (Child) – 1st visit @ Rivertowne Dental


Comprehensive Exam, Prophylaxis (cleaning), 4 Bitewing and Panorex X-rays are FREE

(Cost without discount plan $351)

Preventative Cleaning (Adult or Child) – Routine (every 6 months)


Periodic Exam, Prophylaxis (cleaning) is FREE

(Cost without discount plan $228 Adult & $198 Child)

The enrollment for The Rivertowne Plan is a yearly membership. The membership fee is $269 for an individual member plus $169 for each additional family member(s). This is a yearly contract; therefore it will terminate a year from the enrollment date, unless I renew. This is a discount plan and I am responsible for the fees as set by the office. All fees are subject to change.

The Rivertowne Plan allows me to have dental services at a discounted rate. I understand this plan and the fees are only good at the office of Rivertowne Dental, 6188 Oxon Hill Road, Suite 200, Oxon Hill, MD 20745. If I am referred to a specialist, I understand that I will be charged according to the specialist fees. I cannot use The Rivertowne Plan at any other office.

I understand I will receive one free limited exam and cleaning appointments during the annual term and this will include a Panorex x-ray at the initial cleaning appointment. I also understand I will receive a 50% discount off all other services except implant restoration, whitening treatment and orthodontic treatment; I will receive 20% off implant restoration, whitening treatment and orthodontic treatment.

I can request an estimate of the procedures before treatment. I understand I am responsible for payment at the time of service. I understand the Rivertowne Plan is not an insurance.

Responsible Party Name: DOB:
Responsible Party Signature: Enrollment Date:
Patient Name & DOB Of Enrolled Members: Termination Date:
   
   
Total Annual Fee: Processed By:

QUICK REFERENCE FOR MOST COMMON TREATMENT

Preventative Cleaning (Adult) – 1st visit @ Rivertowne Dental

Basic Restoration – Back Tooth

1 surface amalgam (silver) Filling (cost without discount plan $214)

$107.00

2 surface amalgam (silver) Filling (cost without discount plan $270)

$135.00

3 surface amalgam (silver) Filling (cost without discount plan $330)

$165.00

4 surface amalgam (silver) Filling (cost without discount plan $392)

$196.00

Basic Restoration - Front Tooth

1 surface composite (white) Filling (cost without discount plan $248)

$124.00

2 surface composite (white) Filling (cost without discount plan $302)

$151.00

3 surface composite (white) Filling (cost without discount plan $368)

$184.00

4 surface composite (white) Filling (cost without discount plan $460)

$230.00

Major Restoration

Core Build Up (cost without discount plan $392)

$196.00

Post and Core (cost without discount plan $592)

$296.00

Crown Porcelain Fused to Metal (cost without discount plan $1566)

$783.00

Crown Porcelain/Ceramic (cost without discount plan $1636)

$818.00

Implant Crown & Abutment (cost without discount plan $3500)

$2800.00

QUICK REFERENCE – CONTINUED

Periodontics

Scaling & Root Planing – per quad (cost without discount plan $374)

$187.00

Full Mouth Debridement (cost without discount plan $272)

$136.00

Perio Maintenance (cost without discount plan $200)

$100.00

Endodontic

Root Canal Anterior (cost without discount plan $1094)

$547.00

Root Canal Pre-Molar (cost without discount plan $1242)

$621.00

Root Canal Molar (cost without discount plan $1510)

$755.00

Prosthodontics – Dentures

Partial (cost without discount plan $2664)

$1332.00

Full (cost without discount plan $2620)

$1310.00

Prosthodontics – Dentures

Extraction – Surgical (cost without discount plan $422)

$211.00

Emergency

Limited Oral Exam (cost without discount plan $120)

$60.00

Palliative Treatment (cost without discount plan $196)

$98.00

X-ray Single (cost without discount plan $50)

$25.00

X-ray Additional (cost without discount plan $40)

$20.00

Orthodontics

Records (cost without discount plan $540)

$432.00

Braces (cost without discount plan $6200)

$4960.00

Retainer (cost without discount plan $700)

$560.00

*This is just a quick reference of the most common dental treatment. All treatment recommendations are given in writing and a copy will be provided for your records.