| Dental Cleaning - Adult | $100 | 0% | $100 | 
Medium |
| Dental Cleaning - Child | $71 | 0% | $71 |
Medium |
| Dental Exam - Comprehensive | $98 | 0% | $98 |
Medium |
| Dental Exam - Periodic, Established Patient | $39 | 0% | $39 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $198 | 0% | $198 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $231 | 0% | $231 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $317 | 0% | $317 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $175 | 0% | $175 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $195 | 0% | $195 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $351 | 0% | $351 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $270 | 0% | $270 |
Medium |
| Fluoride - Topical Application | $44 | 0% | $44 |
Medium |
| Maintenance Therapy - Periodontal | $142 | 0% | $142 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $466 | 0% | $466 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | 0% | $90 |
Medium |
| Root Canal - Anterior Tooth | $827 | 0% | $827 |
Medium |
| Root Canal - Bicuspid Tooth | $1,699 | 0% | $1,699 |
Medium |
| Root Canal - Molar | $1,147 | 0% | $1,147 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | 0% | $60 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $188 | 0% | $188 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | 0% | $36 |
Medium |
| X-Ray - Complete Intraoral Series | $150 | 0% | $150 |
Medium |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $52 | 0% | $52 |
Medium |
