| Dental Cleaning - Adult | $125 | 0% | $125 | 
Medium |
| Dental Cleaning - Child | $99 | 0% | $99 |
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 | $281 | 0% | $281 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $415 | 0% | $415 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $357 | 0% | $357 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $240 | 0% | $240 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $281 | 0% | $281 |
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 | $357 | 0% | $357 |
Medium |
| Flouride - Topical Varnish 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 | $1,155 | 0% | $1,155 |
Medium |
| Root Canal - Bicuspid Tooth | $1,276 | 0% | $1,276 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | 0% | $76 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | 0% | $263 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
Medium |
| X-Ray - Complete Intraoral Series | $184 | 0% | $184 |
Medium |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
Medium |
| X-Ray - Two Images, Bitewings | $86 | 0% | $86 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $163 | 0% | $163 |
Medium |
