|Diagnostic and Preventive (includes x-rays, exams, cleaning and sealants)||Free|
|Amalgam Filling: One Surface||$25|
|Root Canal: Molar||$300|
|Gingivectomy, Per Tooth||$50|
|Extraction: Single Tooth, Exposed Root or Erupted||$65|
|Extraction: Complete Bony||$160|
|Crown: Porcelain With Metal||$300|
|Medically Necessary Orthodontia||$350 for children
Not covered for adults
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