| Dental Cleaning - Adult | $108 | 0% | $108 | 
Medium |
| Dental Cleaning - Child | $86 | 0% | $86 |
Medium |
| Dental Exam - Comprehensive | $91 | 0% | $91 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $192 | 0% | $192 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $349 | 0% | $349 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $176 | 0% | $176 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $192 | 0% | $192 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $352 | 0% | $352 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $216 | 0% | $216 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $270 | 0% | $270 |
Medium |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
Medium |
| Fluoride - Topical Application | $47 | 0% | $47 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $299 | 0% | $299 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
Medium |
| Root Canal - Anterior Tooth | $861 | 0% | $861 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $194 | 0% | $194 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $182 | 0% | $182 |
Medium |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $54 | 0% | $54 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $128 | 0% | $128 |
Medium |
