| Dental Cleaning - Adult | $135 | 0% | $135 | 
Medium |
| Dental Cleaning - Child | $110 | 0% | $110 |
Medium |
| Dental Exam - Comprehensive | $158 | 0% | $158 |
Medium |
| Dental Exam - Periodic, Established Patient | $70 | 0% | $70 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $236 | 0% | $236 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $373 | 0% | $373 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $310 | 0% | $310 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $373 | 0% | $373 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $278 | 0% | $278 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $310 | 0% | $310 |
Medium |
| Fluoride - Topical Application | $55 | 0% | $55 |
Medium |
| Maintenance Therapy - Periodontal | $200 | 0% | $200 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | 0% | $341 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $126 | 0% | $126 |
Medium |
| Root Canal - Anterior Tooth | $1,076 | 0% | $1,076 |
Medium |
| Root Canal - Bicuspid Tooth | $1,181 | 0% | $1,181 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $310 | 0% | $310 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Complete Intraoral Series | $179 | 0% | $179 |
Medium |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $179 | 0% | $179 |
Medium |
