| Dental Cleaning - Adult | $122 | 0% | $122 | 
Medium |
| Dental Cleaning - Child | $97 | 0% | $97 |
Medium |
| Dental Exam - Comprehensive | $114 | 0% | $114 |
Medium |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $219 | 0% | $219 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $345 | 0% | $345 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $282 | 0% | $282 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $240 | 0% | $240 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $345 | 0% | $345 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $265 | 0% | $265 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $288 | 0% | $288 |
Medium |
| Flouride - Topical Varnish Application | $55 | 0% | $55 |
Medium |
| Maintenance Therapy - Periodontal | $160 | 0% | $160 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | 0% | $93 |
Medium |
| Root Canal - Molar | $1,322 | 0% | $1,322 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $240 | 0% | $240 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $170 | 0% | $170 |
Medium |
