| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $90 | 0% | $90 |
Medium |
| Dental Exam - Comprehensive | $101 | 0% | $101 |
Medium |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $207 | 0% | $207 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $359 | 0% | $359 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $278 | 0% | $278 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | 0% | $208 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | 0% | $209 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $360 | 0% | $360 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $228 | 0% | $228 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | 0% | $278 |
Medium |
| Fluoride - Topical Application | $47 | 0% | $47 |
Medium |
| Maintenance Therapy - Periodontal | $177 | 0% | $177 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $328 | 0% | $328 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
Medium |
| Root Canal - Anterior Tooth | $980 | 0% | $980 |
Medium |
| Root Canal - Molar | $1,461 | 0% | $1,461 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | 0% | $64 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $249 | 0% | $249 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $175 | 0% | $175 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $152 | 0% | $152 |
Medium |
