| | |
| |
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| Diagnostic | | |
| Periodic Oral Evaluation | $23.00 | $37.00 | $14.00 | 38% |
| Limited Oral Evaluation - Problem Focused | $28.00 | $53.00 | $25.00 | 47% |
| Comprehensive Oral Evaluation | $32.00 | $62.00 | $30.00 | 48% |
| X-ray Intraoral - Complete Series Including Bitewings | $58.00 | $105.00 | $47.00 | 45% |
| X-ray Intraoral Periapical, First Film | $10.00 | $21.00 | $11.00 | 52% |
| X-ray Intraoral Periapical, Each Additional Film | $6.00 | $17.00 | $11.00 | 65% |
| Bitewings, Two Films | $19.00 | $34.00 | $15.00 | 44% |
| Bitewings, Four Films | $25.00 | $49.00 | $24.00 | 49% |
| X-ray Panoramic Film | $46.00 | $89.00 | $43.00 | 48% |
| Preventive | | |
| Prophylaxis - Adult | $45.00 | $70.00 | $25.00 | 36% |
| Prophylaxis - Child | $31.00 | $53.00 | $22.00 | 42% |
| Topical Application of Fluoride (prophylaxis not included) - Child | $17.00 | $27.00 | $10.00 | 37% |
| Topical Application of Fluoride (prophylaxis not included) - Adult | $18.00 | $28.00 | $10.00 | 36% |
| Sealant - Per Tooth | $25.00 | $41.00 | $16.00 | 39% |
| Restorative | | |
| Amalgam - One Surface, Primary or Permanent | $57.00 | $104.00 | $47.00 | 45% |
| Amalgam - Two Surfaces, Primary or Permanent | $71.00 | $129.00 | $58.00 | 45% |
| Amalgam - Three Surfaces, Primary or Permanent | $86.00 | $154.00 | $68.00 | 44% |
| Resin-based Composite - One Surface, Anterior | $70.00 | $123.00 | $53.00 | 43% |
| Resin-based Composite - Two Surfaces, Anterior | $92.00 | $151.00 | $59.00 | 39% |
| Crown-Porcelain Fused to High Noble Metal | $562.00 | $893.00 | $331.00 | 37% |
| Crown-Porcelain Fused to Predominantly Base Metal | $521.00 | $821.00 | $300.00 | 37% |
| Crown-Porcelain Fused to Noble Metal | $544.00 | $866.00 | $322.00 | 37% |
| Endodontics | | |
| Root Canal - Molar (Excluding Final Restoration) | $547.00 | $825.00 | $278.00 | 34% |
| Periodontics | | |
| Osseous Surgery - Four or More Contiguous Teeth or Bounded Teeth Spaces per Quadrant | $572.00 | $870.00 | $298.00 | 34% |
| Periodontal Scaling and Root Planing - Four or More Contiguous Teeth or Bounded Teeth Spaces per Qua | $122.00 | $193.00 | $71.00 | 37% |
| Periodontal Maintenance | $56.00 | $98.00 | $42.00 | 43% |
| Prosthodontics | | |
| Complete Denture - Maxillary | $696.00 | $1,271.00 | $575.00 | 45% |
| Complete Denture - Mandibular | $696.00 | $1,272.00 | $576.00 | 45% |
| Oral and Maxillofacial Surgery | | |
| Surgical Removal of Erupted Tooth | $111.00 | $214.00 | $103.00 | 48% |
| Removal of Impacted Tooth - Completely Bony | $216.00 | $390.00 | $174.00 | 45% |
| Palliative Treatment of Dental Pain | $45.00 | $79.00 | $34.00 | 43% |
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