| Dental Cleaning - Adult | $108 | 0% | $108 | 
Medium |
| Dental Cleaning - Child | $87 | 0% | $87 |
Medium |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
Medium |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $218 | 0% | $218 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $374 | 0% | $374 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $276 | 0% | $276 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | 0% | $200 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $218 | 0% | $218 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $374 | 0% | $374 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $276 | 0% | $276 |
Medium |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
Medium |
| Fluoride - Topical Application | $44 | 0% | $44 |
Medium |
| Maintenance Therapy - Periodontal | $166 | 0% | $166 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $298 | 0% | $298 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | 0% | $90 |
Medium |
| Root Canal - Anterior Tooth | $933 | 0% | $933 |
Medium |
| Root Canal - Bicuspid Tooth | $1,010 | 0% | $1,010 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | 0% | $66 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $214 | 0% | $214 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
Medium |
| X-Ray - Complete Intraoral Series | $159 | 0% | $159 |
Medium |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
Medium |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $147 | 0% | $147 |
Medium |
