| | |
| |
|---|
| Diagnostic | | |
| Periodic Oral Evaluation | $0.00 | $37.00 | $37.00 | 100% |
| Limited Oral Evaluation - Problem Focused | $0.00 | $53.00 | $53.00 | 100% |
| Comprehensive Oral Evaluation | $0.00 | $62.00 | $62.00 | 100% |
| X-ray Intraoral - Complete Series Including Bitewings | $0.00 | $105.00 | $105.00 | 100% |
| X-ray Intraoral Periapical, First Film | $0.00 | $21.00 | $21.00 | 100% |
| X-ray Intraoral Periapical, Each Additional Film | $0.00 | $17.00 | $17.00 | 100% |
| Bitewings, Two Films | $0.00 | $34.00 | $34.00 | 100% |
| Bitewings, Four Films | $0.00 | $49.00 | $49.00 | 100% |
| X-ray Panoramic Film | $0.00 | $89.00 | $89.00 | 100% |
| Preventive | | |
| Prophylaxis - Adult | $0.00 | $70.00 | $70.00 | 100% |
| Prophylaxis - Child | $0.00 | $53.00 | $53.00 | 100% |
| Topical Application of Fluoride (prophylaxis not included) - Child | $0.00 | $27.00 | $27.00 | 100% |
| Topical Application of Fluoride (prophylaxis not included) - Adult | $0.00 | $28.00 | $28.00 | 100% |
| Sealant - Per Tooth | $0.00 | $41.00 | $41.00 | 100% |
| Restorative | | |
| Amalgam - One Surface, Primary or Permanent | $0.00 | $104.00 | $104.00 | 100% |
| Amalgam - Two Surfaces, Primary or Permanent | $0.00 | $129.00 | $129.00 | 100% |
| Amalgam - Three Surfaces, Primary or Permanent | $0.00 | $154.00 | $154.00 | 100% |
| Resin-based Composite - One Surface, Anterior | $0.00 | $123.00 | $123.00 | 100% |
| Resin-based Composite - Two Surfaces, Anterior | $0.00 | $151.00 | $151.00 | 100% |
| Crown-Porcelain Fused to High Noble Metal | $0.00 | $893.00 | $893.00 | 100% |
| Crown-Porcelain Fused to Predominantly Base Metal | $0.00 | $821.00 | $821.00 | 100% |
| Crown-Porcelain Fused to Noble Metal | $0.00 | $866.00 | $866.00 | 100% |
| Endodontics | | |
| Root Canal - Molar (Excluding Final Restoration) | $0.00 | $825.00 | $825.00 | 100% |
| Periodontics | | |
| Osseous Surgery - Four or More Contiguous Teeth or Bounded Teeth Spaces per Quadrant | $0.00 | $870.00 | $870.00 | 100% |
| Periodontal Scaling and Root Planing - Four or More Contiguous Teeth or Bounded Teeth Spaces per Qua | $0.00 | $193.00 | $193.00 | 100% |
| Periodontal Maintenance | $0.00 | $98.00 | $98.00 | 100% |
| Prosthodontics | | |
| Complete Denture - Maxillary | $0.00 | $1,271.00 | $1,271.00 | 100% |
| Complete Denture - Mandibular | $0.00 | $1,272.00 | $1,272.00 | 100% |
| Oral and Maxillofacial Surgery | | |
| Surgical Removal of Erupted Tooth | $0.00 | $214.00 | $214.00 | 100% |
| Removal of Impacted Tooth - Completely Bony | $0.00 | $390.00 | $390.00 | 100% |
| Palliative Treatment of Dental Pain | $0.00 | $79.00 | $79.00 | 100% |
| | | |
