| | |
| |
|---|
| Diagnostic | | |
| Periodic Oral Evaluation | $31.00 | $46.00 | $15.00 | 33% |
| Limited Oral Evaluation - Problem Focused | $36.00 | $57.00 | $21.00 | 37% |
| Comprehensive Oral Evaluation | $40.00 | $66.00 | $26.00 | 39% |
| X-ray Intraoral - Complete Series Including Bitewings | $70.00 | $113.00 | $43.00 | 38% |
| X-ray Intraoral Periapical, First Film | $14.00 | $27.00 | $13.00 | 48% |
| X-ray Intraoral Periapical, Each Additional Film | $6.00 | $16.00 | $10.00 | 63% |
| Bitewings, Two Films | $23.00 | $41.00 | $18.00 | 44% |
| Bitewings, Four Films | $34.00 | $57.00 | $23.00 | 40% |
| X-ray Panoramic Film | $59.00 | $92.00 | $33.00 | 36% |
| Preventive | | |
| Prophylaxis - Adult | $54.00 | $86.00 | $32.00 | 37% |
| Prophylaxis - Child | $40.00 | $66.00 | $26.00 | 39% |
| Topical Application of Fluoride (prophylaxis not included) - Child | $26.00 | $33.00 | $7.00 | 21% |
| Topical Application of Fluoride (prophylaxis not included) - Adult | $26.00 | $35.00 | $9.00 | 26% |
| Sealant - Per Tooth | $27.00 | $49.00 | $22.00 | 45% |
| Restorative | | |
| Amalgam - One Surface, Primary or Permanent | $64.00 | $113.00 | $49.00 | 43% |
| Amalgam - Two Surfaces, Primary or Permanent | $80.00 | $140.00 | $60.00 | 43% |
| Amalgam - Three Surfaces, Primary or Permanent | $102.00 | $168.00 | $66.00 | 39% |
| Resin-based Composite - One Surface, Anterior | $81.00 | $144.00 | $63.00 | 44% |
| Resin-based Composite - Two Surfaces, Anterior | $106.00 | $172.00 | $66.00 | 38% |
| Crown-Porcelain Fused to High Noble Metal | $634.00 | $910.00 | $276.00 | 30% |
| Crown-Porcelain Fused to Predominantly Base Metal | $589.00 | $829.00 | $240.00 | 29% |
| Crown-Porcelain Fused to Noble Metal | $614.00 | $876.00 | $262.00 | 30% |
| Endodontics | | |
| Root Canal - Molar (Excluding Final Restoration) | $610.00 | $831.00 | $221.00 | 27% |
| Periodontics | | |
| Osseous Surgery - Four or More Contiguous Teeth or Bounded Teeth Spaces per Quadrant | $656.00 | $767.00 | $111.00 | 14% |
| Periodontal Scaling and Root Planing - Four or More Contiguous Teeth or Bounded Teeth Spaces per Qua | $127.00 | $202.00 | $75.00 | 37% |
| Periodontal Maintenance | $69.00 | $128.00 | $59.00 | 46% |
| Prosthodontics | | |
| Complete Denture - Maxillary | $828.00 | $1,316.00 | $488.00 | 37% |
| Complete Denture - Mandibular | $828.00 | $1,321.00 | $493.00 | 37% |
| Oral and Maxillofacial Surgery | | |
| Surgical Removal of Erupted Tooth | $144.00 | $225.00 | $81.00 | 36% |
| Removal of Impacted Tooth - Completely Bony | $264.00 | $380.00 | $116.00 | 31% |
| Orthodontics | | |
| Comprehensive Orthodontic Treatment of the Adolescent Dentition | $3,565.00 | $4,384.00 | $819.00 | 19% |
| Comprehensive Orthodontic Treatment of the Adult Dentition | $3,745.00 | $4,634.00 | $889.00 | 19% |
| Palliative Treatment of Dental Pain | $52.00 | $117.00 | $65.00 | 56% |
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