| Dental Cleaning - Adult | $107 | 0% | $107 | 
Medium |
| Dental Cleaning - Child | $118 | 0% | $118 |
Medium |
| Dental Exam - Comprehensive | $80 | 0% | $80 |
Medium |
| Dental Exam - Periodic, Established Patient | $45 | 0% | $45 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $163 | 0% | $163 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $230 | 0% | $230 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $170 | 0% | $170 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $283 | 0% | $283 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $229 | 0% | $229 |
Medium |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
Medium |
| Maintenance Therapy - Periodontal | $149 | 0% | $149 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $250 | 0% | $250 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
Medium |
| Root Canal - Bicuspid Tooth | $961 | 0% | $961 |
Medium |
| Root Canal - Molar | $1,194 | 0% | $1,194 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $20 | 0% | $20 |
Medium |
| X-Ray - Complete Intraoral Series | $139 | 0% | $139 |
Medium |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
Medium |
| X-Ray - Two Images, Bitewings | $46 | 0% | $46 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $136 | 0% | $136 |
Medium |
