| Dental Cleaning - Adult | $119 | 0% | $119 | 
Medium |
| Dental Cleaning - Child | $97 | 0% | $97 |
Medium |
| Dental Exam - Comprehensive | $114 | 0% | $114 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $213 | 0% | $213 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $352 | 0% | $352 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $262 | 0% | $262 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | 0% | $179 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | 0% | $391 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $237 | 0% | $237 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $265 | 0% | $265 |
Medium |
| Fluoride - Topical Application | $45 | 0% | $45 |
Medium |
| Maintenance Therapy - Periodontal | $156 | 0% | $156 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | 0% | $341 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | 0% | $131 |
Medium |
| Root Canal - Anterior Tooth | $1,175 | 0% | $1,175 |
Medium |
| Root Canal - Molar | $1,584 | 0% | $1,584 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | 0% | $70 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $265 | 0% | $265 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $42 | 0% | $42 |
Medium |
| X-Ray - Complete Intraoral Series | $181 | 0% | $181 |
Medium |
| X-Ray - Four Images, Bitewings | $96 | 0% | $96 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | 0% | $46 |
Medium |
| X-Ray - Two Images, Bitewings | $66 | 0% | $66 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $160 | 0% | $160 |
Medium |
