| | |
| |
|---|
| Diagnostic | | |
| Periodic Oral Evaluation | $30.00 | $46.00 | $16.00 | 35% |
| 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 | $72.00 | $113.00 | $41.00 | 36% |
| X-ray Intraoral Periapical, First Film | $14.00 | $27.00 | $13.00 | 48% |
| X-ray Intraoral Periapical, Each Additional Film | $7.00 | $16.00 | $9.00 | 56% |
| Bitewings, Two Films | $23.00 | $41.00 | $18.00 | 44% |
| Bitewings, Four Films | $35.00 | $57.00 | $22.00 | 39% |
| X-ray Panoramic Film | $58.00 | $92.00 | $34.00 | 37% |
| Preventive | | |
| Prophylaxis - Adult | $56.00 | $86.00 | $30.00 | 35% |
| Prophylaxis - Child | $42.00 | $66.00 | $24.00 | 36% |
| Topical Application of Fluoride (prophylaxis not included) - Child | $25.00 | $33.00 | $8.00 | 24% |
| Topical Application of Fluoride (prophylaxis not included) - Adult | $25.00 | $35.00 | $10.00 | 29% |
| Sealant - Per Tooth | $25.00 | $49.00 | $24.00 | 49% |
| Restorative | | |
| Amalgam - One Surface, Primary or Permanent | $65.00 | $113.00 | $48.00 | 42% |
| Amalgam - Two Surfaces, Primary or Permanent | $81.00 | $140.00 | $59.00 | 42% |
| Amalgam - Three Surfaces, Primary or Permanent | $100.00 | $168.00 | $68.00 | 40% |
| Resin-based Composite - One Surface, Anterior | $82.00 | $144.00 | $62.00 | 43% |
| Resin-based Composite - Two Surfaces, Anterior | $98.00 | $172.00 | $74.00 | 43% |
| Crown-Porcelain Fused to High Noble Metal | $607.00 | $910.00 | $303.00 | 33% |
| Crown-Porcelain Fused to Predominantly Base Metal | $565.00 | $829.00 | $264.00 | 32% |
| Crown-Porcelain Fused to Noble Metal | $589.00 | $876.00 | $287.00 | 33% |
| Endodontics | | |
| Root Canal - Molar (Excluding Final Restoration) | $587.00 | $831.00 | $244.00 | 29% |
| Periodontics | | |
| Osseous Surgery - Four or More Contiguous Teeth or Bounded Teeth Spaces per Quadrant | $672.00 | $767.00 | $95.00 | 12% |
| Periodontal Scaling and Root Planing - Four or More Contiguous Teeth or Bounded Teeth Spaces per Qua | $125.00 | $202.00 | $77.00 | 38% |
| Periodontal Maintenance | $66.00 | $128.00 | $62.00 | 48% |
| Prosthodontics | | |
| Complete Denture - Maxillary | $845.00 | $1,316.00 | $471.00 | 36% |
| Complete Denture - Mandibular | $845.00 | $1,321.00 | $476.00 | 36% |
| Oral and Maxillofacial Surgery | | |
| Surgical Removal of Erupted Tooth | $142.00 | $225.00 | $83.00 | 37% |
| Removal of Impacted Tooth - Completely Bony | $244.00 | $380.00 | $136.00 | 36% |
| Orthodontics | | |
| Comprehensive Orthodontic Treatment of the Adolescent Dentition | $3,470.00 | $4,384.00 | $914.00 | 21% |
| Comprehensive Orthodontic Treatment of the Adult Dentition | $3,646.00 | $4,634.00 | $988.00 | 21% |
| Palliative Treatment of Dental Pain | $51.00 | $117.00 | $66.00 | 56% |
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