| Dental Cleaning - Adult | $104 | 0% | $104 | 
Medium |
| Dental Cleaning - Child | $83 | 0% | $83 |
Medium |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $211 | 0% | $211 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $337 | 0% | $337 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $173 | 0% | $173 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $204 | 0% | $204 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $337 | 0% | $337 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $223 | 0% | $223 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
Medium |
| Flouride - Topical Varnish Application | $38 | 0% | $38 |
Medium |
| Fluoride - Topical Application | $37 | 0% | $37 |
Medium |
| Maintenance Therapy - Periodontal | $162 | 0% | $162 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $331 | 0% | $331 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | 0% | $97 |
Medium |
| Root Canal - Anterior Tooth | $735 | 0% | $735 |
Medium |
| Root Canal - Bicuspid Tooth | $961 | 0% | $961 |
Medium |
| Root Canal - Molar | $1,217 | 0% | $1,217 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $208 | 0% | $208 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
Medium |
| X-Ray - Complete Intraoral Series | $179 | 0% | $179 |
Medium |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
Medium |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $127 | 0% | $127 |
Medium |
