| Dental Cleaning - Adult | $89 | 0% | $89 | 
Medium |
| Dental Cleaning - Child | $68 | 0% | $68 |
Medium |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
Medium |
| Dental Exam - Periodic, Established Patient | $48 | 0% | $48 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $351 | 0% | $351 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $218 | 0% | $218 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $347 | 0% | $347 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | 0% | $167 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $347 | 0% | $347 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $281 | 0% | $281 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $216 | 0% | $216 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $445 | 0% | $445 |
Medium |
| Flouride - Topical Varnish Application | $38 | 0% | $38 |
Medium |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $230 | 0% | $230 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $74 | 0% | $74 |
Medium |
| Root Canal - Anterior Tooth | $701 | 0% | $701 |
Medium |
| Root Canal - Bicuspid Tooth | $1,217 | 0% | $1,217 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $53 | 0% | $53 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $160 | 0% | $160 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
Medium |
| X-Ray - Complete Intraoral Series | $122 | 0% | $122 |
Medium |
| X-Ray - Four Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
Medium |
| X-Ray - Two Images, Bitewings | $88 | 0% | $88 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $110 | 0% | $110 |
Medium |
