Dental Cleaning - Adult | $130 | N/A | $130 |
Dental Cleaning - Child | $89 | N/A | $89 |
Dental Exam - Comprehensive | $120 | N/A | $120 |
Dental Exam - Periodic, Established Patient | $71 | N/A | $71 |
Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
Dental Filling - White (Resin): One Surface, Anterior | $192 | N/A | $192 |
Dental Filling - White (Resin): One Surface, Posterior | $208 | N/A | $208 |
Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | N/A | $347 |
Dental Filling - White (Resin): Two Surfaces, Anterior | $275 | N/A | $275 |
Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
Flouride - Topical Varnish Application | $51 | N/A | $51 |
Fluoride - Topical Application | $71 | N/A | $71 |
Maintenance Therapy - Periodontal | $190 | N/A | $190 |
Orthodontic Treatment - Periodic Visit, Part of a Contract | $161 | N/A | $161 |
Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | N/A | $103 |
Sealant - Placed on Tooth Surface to Prevent Decay | $70 | N/A | $70 |
Tooth Extraction - Elevation and/or Forceps Removal | $247 | N/A | $247 |
X-Ray - Complete Intraoral Series | $200 | N/A | $200 |
X-Ray - Four Images, Bitewings | $92 | N/A | $92 |
X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
X-Ray - Two Images, Bitewings | $78 | N/A | $78 |