Description
|
Discounted Fee
|
| Periodic Oral Evaluation |
$27 |
| Limited Oral Evaluation - Problem Focused |
$33 |
| Comprehensive Oral Evaluation |
$39 |
| X-ray Intraoral - Complete Series Including Bitewings |
$70 |
| X-ray Intraoral Periapical, First Film |
$13 |
| X-ray Intraoral Periapical, Each Additional Film |
$7 |
| X-ray Bitewing, Single Film |
$13 |
| Bitewings, Two Films |
$22 |
| Bitewings, Four Films |
$31 |
| X-ray Panoramic Film |
$58 |
| Prophylaxis - Adult |
$53 |
| Prophylaxis - Child |
$37 |
| Topical Application of Fluoride (prophylaxis not included) - Child |
$23 |
| Topical Application of Fluoride (prophylaxis not included) - Adult |
$23 |
| Sealant - Per Tooth |
$25 |
| Amalgam - One Surface, Primary or Permanent |
$66 |
| Amalgam - Two Surfaces, Primary or Permanent |
$82 |
| Amalgam - Three Surfaces, Primary or Permanent |
$101 |
| Resin-based Composite - One Surface, Anterior |
$77 |
| Resin-based Composite - Two Surfaces, Anterior |
$99 |
| Crown-Porcelain Fused to High Noble Metal |
$640 |
| Crown-Porcelain Fused to Predominantly Base Metal |
$596 |
| Crown-Porcelain Fused to Noble Metal |
$619 |
| Root Canal - Molar (Excluding Final Restoration) |
$619 |
Osseous Surgery - Four or More Contiguous Teeth or Contiguous
Teeth or Bounded Teeth Spaces per Quadrant |
$663 |
Periodontal Scaling and Root Planing - Four or More
Contiguous
Teeth or Bounded Teeth Spaces per Quadrant |
$127 |
| Periodontal Maintenance |
$66 |
| Complete Denture - Maxillary |
$804 |
| Complete Denture - Mandibular |
$806 |
| Surgical Removal of Erupted Tooth |
$140 |
| Removal of Impacted Tooth - Completely Bony |
$253 |
| Comprehensive Orthodontic Treatment of the Adolescent
Dentition |
$3,412 |
| Comprehensive Orthodontic Treatment of the Adult Dentition |
$3,586 |
| Palliative Treatment of Dental Pain |
$49 |
