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.
