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| |
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| Diagnostic | | |
| Periodic Oral Evaluation | $24.00 | $37.00 | $13.00 | 35% |
| Limited Oral Evaluation - Problem Focused | $28.00 | $49.00 | $21.00 | 43% |
| Comprehensive Oral Evaluation | $35.00 | $58.00 | $23.00 | 40% |
| X-ray Intraoral - Complete Series Including Bitewings | $59.00 | $103.00 | $44.00 | 43% |
| X-ray Intraoral Periapical, First Film | $11.00 | $21.00 | $10.00 | 48% |
| X-ray Intraoral Periapical, Each Additional Film | $5.00 | $17.00 | $12.00 | 71% |
| Bitewings, Two Films | $20.00 | $33.00 | $13.00 | 39% |
| Bitewings, Four Films | $27.00 | $47.00 | $20.00 | 43% |
| X-ray Panoramic Film | $49.00 | $83.00 | $34.00 | 41% |
| Preventive | | |
| Prophylaxis - Adult | $47.00 | $75.00 | $28.00 | 37% |
| Prophylaxis - Child | $31.00 | $54.00 | $23.00 | 43% |
| Topical Application of Fluoride (prophylaxis not included) - Child | $18.00 | $25.00 | $7.00 | 28% |
| Topical Application of Fluoride (prophylaxis not included) - Adult | $18.00 | $27.00 | $9.00 | 33% |
| Sealant - Per Tooth | $23.00 | $39.00 | $16.00 | 41% |
| Restorative | | |
| Amalgam - One Surface, Primary or Permanent | $56.00 | $102.00 | $46.00 | 45% |
| Amalgam - Two Surfaces, Primary or Permanent | $74.00 | $130.00 | $56.00 | 43% |
| Amalgam - Three Surfaces, Primary or Permanent | $92.00 | $154.00 | $62.00 | 40% |
| Resin-based Composite - One Surface, Anterior | $73.00 | $125.00 | $52.00 | 42% |
| Resin-based Composite - Two Surfaces, Anterior | $99.00 | $254.00 | $155.00 | 61% |
| Crown-Porcelain Fused to High Noble Metal | $603.00 | $838.00 | $235.00 | 28% |
| Crown-Porcelain Fused to Predominantly Base Metal | $560.00 | $794.00 | $234.00 | 29% |
| Crown-Porcelain Fused to Noble Metal | $585.00 | $823.00 | $238.00 | 29% |
| Endodontics | | |
| Root Canal - Molar (Excluding Final Restoration) | $581.00 | $773.00 | $192.00 | 25% |
| Periodontics | | |
| Osseous Surgery - Four or More Contiguous Teeth or Bounded Teeth Spaces per Quadrant | $593.00 | $738.00 | $145.00 | 20% |
| Periodontal Scaling and Root Planing - Four or More Contiguous Teeth or Bounded Teeth Spaces per Qua | $127.00 | $194.00 | $67.00 | 35% |
| Periodontal Maintenance | $61.00 | $106.00 | $45.00 | 42% |
| Prosthodontics | | |
| Complete Denture - Maxillary | $719.00 | $1,290.00 | $571.00 | 44% |
| Complete Denture - Mandibular | $719.00 | $1,293.00 | $574.00 | 44% |
| Oral and Maxillofacial Surgery | | |
| Surgical Removal of Erupted Tooth | $142.00 | $195.00 | $53.00 | 27% |
| Removal of Impacted Tooth - Completely Bony | $234.00 | $328.00 | $94.00 | 29% |
| Palliative Treatment of Dental Pain | $50.00 | $99.00 | $49.00 | 49% |
| | | |
