| Dental Cleaning - Adult | $107 | 0% | $107 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $217 | 0% | $217 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $337 | 0% | $337 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $172 | 0% | $172 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | 0% | $209 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $339 | 0% | $339 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $281 | 0% | $281 |
Medium |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
Medium |
| Fluoride - Topical Application | $37 | 0% | $37 |
Medium |
| Maintenance Therapy - Periodontal | $165 | 0% | $165 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $303 | 0% | $303 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
Medium |
| Root Canal - Anterior Tooth | $735 | 0% | $735 |
Medium |
| Root Canal - Bicuspid Tooth | $961 | 0% | $961 |
Medium |
| Root Canal - Molar | $1,196 | 0% | $1,196 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $273 | 0% | $273 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
Medium |
| X-Ray - Complete Intraoral Series | $187 | 0% | $187 |
Medium |
| X-Ray - Four Images, Bitewings | $77 | 0% | $77 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
Medium |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $138 | 0% | $138 |
Medium |
