| Dental Cleaning - Adult | $119 | 0% | $119 | 
Medium |
| Dental Cleaning - Child | $86 | 0% | $86 |
Medium |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $233 | 0% | $233 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $392 | 0% | $392 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $297 | 0% | $297 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $175 | 0% | $175 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | 0% | $233 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $392 | 0% | $392 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $219 | 0% | $219 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $297 | 0% | $297 |
Medium |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
Medium |
| Maintenance Therapy - Periodontal | $155 | 0% | $155 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $291 | 0% | $291 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
Medium |
| Root Canal - Bicuspid Tooth | $1,097 | 0% | $1,097 |
Medium |
| Root Canal - Molar | $1,274 | 0% | $1,274 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $338 | 0% | $338 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
Medium |
| X-Ray - Complete Intraoral Series | $164 | 0% | $164 |
Medium |
| X-Ray - Four Images, Bitewings | $78 | 0% | $78 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $130 | 0% | $130 |
Medium |
