| Dental Cleaning - Adult | $117 | 0% | $117 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $110 | 0% | $110 |
Medium |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $218 | 0% | $218 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $349 | 0% | $349 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $281 | 0% | $281 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $203 | 0% | $203 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $349 | 0% | $349 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $254 | 0% | $254 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $281 | 0% | $281 |
Medium |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
Medium |
| Maintenance Therapy - Periodontal | $168 | 0% | $168 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $315 | 0% | $315 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | 0% | $102 |
Medium |
| Root Canal - Bicuspid Tooth | $1,092 | 0% | $1,092 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $212 | 0% | $212 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Complete Intraoral Series | $169 | 0% | $169 |
Medium |
| X-Ray - Four Images, Bitewings | $81 | 0% | $81 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $166 | 0% | $166 |
Medium |
