| Dental Cleaning - Adult | $104 | 0% | $104 | 
Medium |
| Dental Cleaning - Child | $104 | 0% | $104 |
Medium |
| Dental Exam - Comprehensive | $158 | 0% | $158 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $142 | 0% | $142 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $176 | 0% | $176 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $160 | 0% | $160 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $188 | 0% | $188 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $196 | 0% | $196 |
Medium |
| Fluoride - Topical Application | $60 | 0% | $60 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| Root Canal - Anterior Tooth | $852 | 0% | $852 |
Medium |
| Root Canal - Bicuspid Tooth | $919 | 0% | $919 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $363 | 0% | $363 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $145 | 0% | $145 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
