| | |
| |
|---|
| Diagnostic | | |
| Periodic Oral Evaluation | $24.00 | $33.00 | $9.00 | 27% |
| Limited Oral Evaluation - Problem Focused | $28.00 | $49.00 | $21.00 | 43% |
| Comprehensive Oral Evaluation | $34.00 | $54.00 | $20.00 | 37% |
| X-ray Intraoral - Complete Series Including Bitewings | $58.00 | $92.00 | $34.00 | 37% |
| X-ray Intraoral Periapical, First Film | $11.00 | $19.00 | $8.00 | 42% |
| X-ray Intraoral Periapical, Each Additional Film | $6.00 | $15.00 | $9.00 | 60% |
| Bitewings, Two Films | $19.00 | $30.00 | $11.00 | 37% |
| Bitewings, Four Films | $25.00 | $44.00 | $19.00 | 43% |
| X-ray Panoramic Film | $42.00 | $79.00 | $37.00 | 47% |
| Preventive | | |
| Prophylaxis - Adult | $50.00 | $63.00 | $13.00 | 21% |
| Prophylaxis - Child | $35.00 | $49.00 | $14.00 | 29% |
| Topical Application of Fluoride (prophylaxis not included) - Child | $15.00 | $23.00 | $8.00 | 35% |
| Topical Application of Fluoride (prophylaxis not included) - Adult | $15.00 | $23.00 | $8.00 | 35% |
| Sealant - Per Tooth | $26.00 | $37.00 | $11.00 | 30% |
| Restorative | | |
| Amalgam - One Surface, Primary or Permanent | $60.00 | $92.00 | $32.00 | 35% |
| Amalgam - Two Surfaces, Primary or Permanent | $85.00 | $118.00 | $33.00 | 28% |
| Amalgam - Three Surfaces, Primary or Permanent | $104.00 | $143.00 | $39.00 | 27% |
| Resin-based Composite - One Surface, Anterior | $84.00 | $108.00 | $24.00 | 22% |
| Resin-based Composite - Two Surfaces, Anterior | $115.00 | $134.00 | $19.00 | 14% |
| Crown-Porcelain Fused to High Noble Metal | $685.00 | $816.00 | $131.00 | 16% |
| Crown-Porcelain Fused to Predominantly Base Metal | $636.00 | $743.00 | $107.00 | 14% |
| Crown-Porcelain Fused to Noble Metal | $664.00 | $800.00 | $136.00 | 17% |
| Endodontics | | |
| Root Canal - Molar (Excluding Final Restoration) | $609.00 | $761.00 | $152.00 | 20% |
| Periodontics | | |
| Osseous Surgery - Four or More Contiguous Teeth or Bounded Teeth Spaces per Quadrant | $631.00 | $725.00 | $94.00 | 13% |
| Periodontal Scaling and Root Planing - Four or More Contiguous Teeth or Bounded Teeth Spaces per Qua | $147.00 | $177.00 | $30.00 | 17% |
| Periodontal Maintenance | $64.00 | $94.00 | $30.00 | 32% |
| Prosthodontics | | |
| Complete Denture - Maxillary | $814.00 | $1,133.00 | $319.00 | 28% |
| Complete Denture - Mandibular | $814.00 | $1,138.00 | $324.00 | 28% |
| Oral and Maxillofacial Surgery | | |
| Surgical Removal of Erupted Tooth | $140.00 | $186.00 | $46.00 | 25% |
| Removal of Impacted Tooth - Completely Bony | $268.00 | $337.00 | $69.00 | 20% |
| Palliative Treatment of Dental Pain | $46.00 | $75.00 | $29.00 | 39% |
| | | |
