| Dental Cleaning - Adult | $92 | 0% | $92 | 
Medium |
| Dental Cleaning - Child | $67 | 0% | $67 |
Medium |
| Dental Exam - Comprehensive | $86 | 0% | $86 |
Medium |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $156 | 0% | $156 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $206 | 0% | $206 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $176 | 0% | $176 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $160 | 0% | $160 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $172 | 0% | $172 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $428 | 0% | $428 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $183 | 0% | $183 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $202 | 0% | $202 |
Medium |
| Fluoride - Topical Application | $42 | 0% | $42 |
Medium |
| Maintenance Therapy - Periodontal | $206 | 0% | $206 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $205 | 0% | $205 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $84 | 0% | $84 |
Medium |
| Root Canal - Anterior Tooth | $940 | 0% | $940 |
Medium |
| Root Canal - Bicuspid Tooth | $1,003 | 0% | $1,003 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $48 | 0% | $48 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | 0% | $189 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $126 | 0% | $126 |
Medium |
| X-Ray - Four Images, Bitewings | $61 | 0% | $61 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $48 | 0% | $48 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $128 | 0% | $128 |
Medium |
