Dental Cleaning - Adult | $96 | N/A | $96 |
Dental Cleaning - Child | $72 | N/A | $72 |
Dental Exam - Comprehensive | $102 | N/A | $102 |
Dental Exam - Periodic, Established Patient | $43 | N/A | $43 |
Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $191 | N/A | $191 |
Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $340 | N/A | $340 |
Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | N/A | $261 |
Dental Filling - White (Resin): One Surface, Anterior | $187 | N/A | $187 |
Dental Filling - White (Resin): One Surface, Posterior | $202 | N/A | $202 |
Dental Filling - White (Resin): Three Surfaces, Posterior | $340 | N/A | $340 |
Dental Filling - White (Resin): Two Surfaces, Anterior | $229 | N/A | $229 |
Dental Filling - White (Resin): Two Surfaces, Posterior | $217 | N/A | $217 |
Flouride - Topical Varnish Application | $38 | N/A | $38 |
Fluoride - Topical Application | $43 | N/A | $43 |
Maintenance Therapy - Periodontal | $138 | N/A | $138 |
Orthodontic Treatment - Periodic Visit, Part of a Contract | $91 | N/A | $91 |
Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $285 | N/A | $285 |
Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
Root Canal - Anterior Tooth | $735 | N/A | $735 |
Root Canal - Bicuspid Tooth | $1,024 | N/A | $1,024 |
Root Canal - Molar | $1,231 | N/A | $1,231 |
Sealant - Placed on Tooth Surface to Prevent Decay | $50 | N/A | $50 |
Tooth Extraction - Elevation and/or Forceps Removal | $155 | N/A | $155 |
X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | N/A | $24 |
X-Ray - Complete Intraoral Series | $153 | N/A | $153 |
X-Ray - Four Images, Bitewings | $61 | N/A | $61 |
X-Ray - Intraoral, Periapical Radiographic Image | $35 | N/A | $35 |
X-Ray - Two Images, Bitewings | $44 | N/A | $44 |