| Dental Cleaning - Adult | $108 | 0% | $108 | 
Medium |
| Dental Cleaning - Child | $87 | 0% | $87 |
Medium |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $218 | 0% | $218 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $341 | 0% | $341 |
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 | $342 | 0% | $342 |
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 | $43 | 0% | $43 |
Medium |
| Maintenance Therapy - Periodontal | $166 | 0% | $166 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $286 | 0% | $286 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| Root Canal - Bicuspid Tooth | $1,010 | 0% | $1,010 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | 0% | $64 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $209 | 0% | $209 |
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 | $71 | 0% | $71 |
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 |
