| Dental Cleaning - Adult | $120 | 0% | $120 | 
Medium |
| Dental Cleaning - Child | $86 | 0% | $86 |
Medium |
| Dental Exam - Comprehensive | $103 | 0% | $103 |
Medium |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $213 | 0% | $213 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $345 | 0% | $345 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $278 | 0% | $278 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | 0% | $200 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $213 | 0% | $213 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $345 | 0% | $345 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $240 | 0% | $240 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | 0% | $278 |
Medium |
| Flouride - Topical Varnish Application | $70 | 0% | $70 |
Medium |
| Fluoride - Topical Application | $43 | 0% | $43 |
Medium |
| Maintenance Therapy - Periodontal | $180 | 0% | $180 |
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 | $106 | 0% | $106 |
Medium |
| Root Canal - Anterior Tooth | $1,004 | 0% | $1,004 |
Medium |
| Root Canal - Bicuspid Tooth | $1,231 | 0% | $1,231 |
Medium |
| Root Canal - Molar | $1,526 | 0% | $1,526 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $227 | 0% | $227 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
Medium |
| X-Ray - Complete Intraoral Series | $234 | 0% | $234 |
Medium |
| X-Ray - Four Images, Bitewings | $82 | 0% | $82 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $43 | 0% | $43 |
Medium |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $152 | 0% | $152 |
Medium |
