| Periodic oral evaluation |
$24.00 |
| Limited oral evaluation |
$50.00 |
| Comprehensive oral evaluation |
$24.00 |
| Intraoral - full series |
$83.00 |
| Prophylaxis - adult |
$72.00 |
| Prophylaxis - child (with fluoride) |
$61.00 |
| Intraoral - periapical - 1st film |
$11.00 |
| Intraoral - periapical - each additional film |
$8.00 |
| Bitewing - single film |
$11.00 |
| Bitewings - two films |
$20.00 |
| Bitewings - four films |
$39.00 |
| Sealant (per tooth) |
$28.00 |
| Amalgam - 1 surface (prim/perm) |
$66.00 |
| Amalgam - 2 surfaces (prim/perm) |
$83.00 |
| Amalgam - 3 surfaces (prim/perm) |
$105.00 |
| Amalgam - 4+ surfaces (prim/perm) |
$138.00 |
| White filling - 1 surface anterior |
$88.00 |
| White filling - 2 surface anterior |
$143.00 |
| White filling - 3 surface anterior |
$165.00 |
| White filling - 4+ surface anterior |
$193.00 |
| White filling - 1 surface post (prim/perm) |
$88.00 |
| White filling - 2 surface post (prim/perm) |
$143.00 |
| White filling - 3 surface post (prim/perm) |
$165.00 |
| White filling - 4 surface post (prim/perm) |
$193.00 |
| Crown-porcelain fused to metal base |
$655.00 |
| In-office whitening |
$495.00 |
| Take-home bleaching |
$275.00 |
| Recement crown |
$50.00 |
| Prefab stainless steel crown (primary) |
$150.00 |
| Sedative filling |
$50.00 |
| Crown buildup, including pins |
$138.00 |
| Cast post & core (in additional to crown) |
$215.00 |
| Prefab post & core (in additional to crown) |
$160.00 |
| Labial veneer (porcelain lam) -lab |
$765.00 |
| Therapeutic pulpotomy (excludes rest) |
$83.00 |
| Root canal therapy - anterior |
$424.00 |
| Root canal therapy - bicuspid |
$523.00 |
| Root canal therapy - molar |
$721.00 |
| Retreat, prev RCT - molar |
$770.00 |
| Periodontal scale & root pin (4 per quad) |
$110.00 |
| Periodontal scale 1-3 teeth |
$83.00 |
| Full mouth debridement, evaluation & diagnose |
$110.00 |
| Periodontal maintenance |
$138.00 |
| Complete denture - maxillary |
$765.00 |
| Complete denture - mandibular |
$765.00 |
| Immediate denture - maxillary |
$765.00 |
| Immediate denture - mandibular |
$765.00 |
| Maxillary partial-metal base w/sdls |
$765.00 |
| Mandibular partial-metal base w/sdls |
$765.00 |
| Pontic-porcelian fused to base |
$765.00 |
| Retainer crown-porcelain fused to base |
$710.00 |
| Recement bridge |
$110.00 |
| Application of desensitize medication |
$55.00 |
| No show (cancellation less than 24 hours of app't) |
$39.00 |
| Occlusal guards, by report |
$275.00 |
