| Dental Cleaning - Adult | $125 | 0% | $125 | 
Medium |
| Dental Cleaning - Child | $93 | 0% | $93 |
Medium |
| Dental Exam - Comprehensive | $130 | 0% | $130 |
Medium |
| Dental Exam - Periodic, Established Patient | $70 | 0% | $70 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $251 | 0% | $251 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $384 | 0% | $384 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $319 | 0% | $319 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $240 | 0% | $240 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $253 | 0% | $253 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $384 | 0% | $384 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $282 | 0% | $282 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $319 | 0% | $319 |
Medium |
| Flouride - Topical Varnish Application | $60 | 0% | $60 |
Medium |
| Fluoride - Topical Application | $60 | 0% | $60 |
Medium |
| Maintenance Therapy - Periodontal | $188 | 0% | $188 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $353 | 0% | $353 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | 0% | $104 |
Medium |
| Root Canal - Anterior Tooth | $999 | 0% | $999 |
Medium |
| Root Canal - Bicuspid Tooth | $1,109 | 0% | $1,109 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | 0% | $76 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $251 | 0% | $251 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | 0% | $36 |
Medium |
| X-Ray - Complete Intraoral Series | $176 | 0% | $176 |
Medium |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
Medium |
| X-Ray - Two Images, Bitewings | $67 | 0% | $67 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $151 | 0% | $151 |
Medium |
