| | |
| |
|---|
| Diagnostic | | |
| Periodic Oral Evaluation | $19.00 | $33.00 | $14.00 | 42% |
| Limited Oral Evaluation - Problem Focused | $23.00 | $49.00 | $26.00 | 53% |
| Comprehensive Oral Evaluation | $30.00 | $54.00 | $24.00 | 44% |
| X-ray Intraoral - Complete Series Including Bitewings | $55.00 | $92.00 | $37.00 | 40% |
| X-ray Intraoral Periapical, First Film | $10.00 | $19.00 | $9.00 | 47% |
| X-ray Intraoral Periapical, Each Additional Film | $6.00 | $15.00 | $9.00 | 60% |
| Bitewings, Two Films | $18.00 | $30.00 | $12.00 | 40% |
| Bitewings, Four Films | $24.00 | $44.00 | $20.00 | 45% |
| X-ray Panoramic Film | $42.00 | $79.00 | $37.00 | 47% |
| Preventive | | |
| Prophylaxis - Adult | $41.00 | $63.00 | $22.00 | 35% |
| Prophylaxis - Child | $29.00 | $49.00 | $20.00 | 41% |
| Topical Application of Fluoride (prophylaxis not included) - Child | $17.00 | $23.00 | $6.00 | 26% |
| Topical Application of Fluoride (prophylaxis not included) - Adult | $17.00 | $23.00 | $6.00 | 26% |
| Sealant - Per Tooth | $26.00 | $37.00 | $11.00 | 30% |
| Restorative | | |
| Amalgam - One Surface, Primary or Permanent | $55.00 | $92.00 | $37.00 | 40% |
| Amalgam - Two Surfaces, Primary or Permanent | $72.00 | $118.00 | $46.00 | 39% |
| Amalgam - Three Surfaces, Primary or Permanent | $83.00 | $143.00 | $60.00 | 42% |
| Resin-based Composite - One Surface, Anterior | $65.00 | $108.00 | $43.00 | 40% |
| Resin-based Composite - Two Surfaces, Anterior | $81.00 | $134.00 | $53.00 | 40% |
| Crown-Porcelain Fused to High Noble Metal | $528.00 | $816.00 | $288.00 | 35% |
| Crown-Porcelain Fused to Predominantly Base Metal | $491.00 | $743.00 | $252.00 | 34% |
| Crown-Porcelain Fused to Noble Metal | $512.00 | $800.00 | $288.00 | 36% |
| Endodontics | | |
| Root Canal - Molar (Excluding Final Restoration) | $507.00 | $761.00 | $254.00 | 33% |
| Periodontics | | |
| Osseous Surgery - Four or More Contiguous Teeth or Bounded Teeth Spaces per Quadrant | $548.00 | $725.00 | $177.00 | 24% |
| Periodontal Scaling and Root Planing - Four or More Contiguous Teeth or Bounded Teeth Spaces per Qua | $119.00 | $177.00 | $58.00 | 33% |
| Periodontal Maintenance | $54.00 | $94.00 | $40.00 | 43% |
| Prosthodontics | | |
| Complete Denture - Maxillary | $720.00 | $1,133.00 | $413.00 | 36% |
| Complete Denture - Mandibular | $720.00 | $1,138.00 | $418.00 | 37% |
| Oral and Maxillofacial Surgery | | |
| Surgical Removal of Erupted Tooth | $108.00 | $186.00 | $78.00 | 42% |
| Removal of Impacted Tooth - Completely Bony | $200.00 | $337.00 | $137.00 | 41% |
| Palliative Treatment of Dental Pain | $40.00 | $75.00 | $35.00 | 47% |
| | | |
