| Dental Cleaning - Adult | $131 | 0% | $131 | 
Medium |
| Dental Cleaning - Child | $172 | 0% | $172 |
Medium |
| Dental Exam - Comprehensive | $158 | 0% | $158 |
Medium |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $244 | 0% | $244 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $331 | 0% | $331 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $244 | 0% | $244 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $354 | 0% | $354 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $289 | 0% | $289 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $326 | 0% | $326 |
Medium |
| Fluoride - Topical Application | $51 | 0% | $51 |
Medium |
| Maintenance Therapy - Periodontal | $210 | 0% | $210 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $320 | 0% | $320 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | 0% | $103 |
Medium |
| Root Canal - Anterior Tooth | $1,990 | 0% | $1,990 |
Medium |
| Root Canal - Bicuspid Tooth | $1,155 | 0% | $1,155 |
Medium |
| Root Canal - Molar | $1,460 | 0% | $1,460 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $242 | 0% | $242 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
Medium |
| X-Ray - Complete Intraoral Series | $179 | 0% | $179 |
Medium |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
Medium |
| X-Ray - Two Images, Bitewings | $120 | 0% | $120 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $173 | 0% | $173 |
Medium |
