| Dental Cleaning - Adult | $100 | 0% | $100 | 
Medium |
| Dental Cleaning - Child | $74 | 0% | $74 |
Medium |
| Dental Exam - Comprehensive | $98 | 0% | $98 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $336 | 0% | $336 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | 0% | $165 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $336 | 0% | $336 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | 0% | $202 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
Medium |
| Fluoride - Topical Application | $27 | 0% | $27 |
Medium |
| Maintenance Therapy - Periodontal | $140 | 0% | $140 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $276 | 0% | $276 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| Root Canal - Bicuspid Tooth | $979 | 0% | $979 |
Medium |
| Root Canal - Molar | $1,219 | 0% | $1,219 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $148 | 0% | $148 |
Medium |
| X-Ray - Four Images, Bitewings | $77 | 0% | $77 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $137 | 0% | $137 |
Medium |
