| | |
| |
|---|
| Diagnostic | | |
| Periodic Oral Evaluation | $29.00 | $39.00 | $10.00 | 26% |
| Limited Oral Evaluation - Problem Focused | $34.00 | $50.00 | $16.00 | 32% |
| Comprehensive Oral Evaluation | $43.00 | $58.00 | $15.00 | 26% |
| X-ray Intraoral - Complete Series Including Bitewings | $74.00 | $102.00 | $28.00 | 27% |
| X-ray Intraoral Periapical, First Film | $14.00 | $20.00 | $6.00 | 30% |
| X-ray Intraoral Periapical, Each Additional Film | $6.00 | $15.00 | $9.00 | 60% |
| Bitewings, Two Films | $22.00 | $32.00 | $10.00 | 31% |
| Bitewings, Four Films | $32.00 | $48.00 | $16.00 | 33% |
| X-ray Panoramic Film | $63.00 | $88.00 | $25.00 | 28% |
| Preventive | | |
| Prophylaxis - Adult | $62.00 | $78.00 | $16.00 | 21% |
| Prophylaxis - Child | $37.00 | $56.00 | $19.00 | 34% |
| Topical Application of Fluoride (prophylaxis not included) - Child | $22.00 | $30.00 | $8.00 | 27% |
| Topical Application of Fluoride (prophylaxis not included) - Adult | $22.00 | $31.00 | $9.00 | 29% |
| Sealant - Per Tooth | $26.00 | $41.00 | $15.00 | 37% |
| Restorative | | |
| Amalgam - One Surface, Primary or Permanent | $64.00 | $94.00 | $30.00 | 32% |
| Amalgam - Two Surfaces, Primary or Permanent | $79.00 | $123.00 | $44.00 | 36% |
| Amalgam - Three Surfaces, Primary or Permanent | $102.00 | $149.00 | $47.00 | 32% |
| Resin-based Composite - One Surface, Anterior | $78.00 | $113.00 | $35.00 | 31% |
| Resin-based Composite - Two Surfaces, Anterior | $104.00 | $146.00 | $42.00 | 29% |
| Crown-Porcelain Fused to High Noble Metal | $689.00 | $912.00 | $223.00 | 24% |
| Crown-Porcelain Fused to Predominantly Base Metal | $642.00 | $836.00 | $194.00 | 23% |
| Crown-Porcelain Fused to Noble Metal | $669.00 | $885.00 | $216.00 | 24% |
| Endodontics | | |
| Root Canal - Molar (Excluding Final Restoration) | $715.00 | $806.00 | $91.00 | 11% |
| Periodontics | | |
| Osseous Surgery - Four or More Contiguous Teeth or Bounded Teeth Spaces per Quadrant | $656.00 | $790.00 | $134.00 | 17% |
| Periodontal Scaling and Root Planing - Four or More Contiguous Teeth or Bounded Teeth Spaces per Qua | $124.00 | $179.00 | $55.00 | 31% |
| Periodontal Maintenance | $75.00 | $103.00 | $28.00 | 27% |
| Prosthodontics | | |
| Complete Denture - Maxillary | $835.00 | $1,255.00 | $420.00 | 33% |
| Complete Denture - Mandibular | $835.00 | $1,256.00 | $421.00 | 34% |
| Oral and Maxillofacial Surgery | | |
| Surgical Removal of Erupted Tooth | $147.00 | $214.00 | $67.00 | 31% |
| Removal of Impacted Tooth - Completely Bony | $293.00 | $398.00 | $105.00 | 26% |
| Palliative Treatment of Dental Pain | $49.00 | $81.00 | $32.00 | 40% |
| | | |
