| Dental Cleaning - Adult | $127 | 0% | $127 | 
Medium |
| Dental Cleaning - Child | $99 | 0% | $99 |
Medium |
| Dental Exam - Comprehensive | $113 | 0% | $113 |
Medium |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $226 | 0% | $226 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $412 | 0% | $412 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $287 | 0% | $287 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $215 | 0% | $215 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | 0% | $226 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $412 | 0% | $412 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $247 | 0% | $247 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $398 | 0% | $398 |
Medium |
| Fluoride - Topical Application | $53 | 0% | $53 |
Medium |
| Maintenance Therapy - Periodontal | $163 | 0% | $163 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $296 | 0% | $296 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | 0% | $110 |
Medium |
| Root Canal - Anterior Tooth | $895 | 0% | $895 |
Medium |
| Root Canal - Bicuspid Tooth | $1,005 | 0% | $1,005 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $203 | 0% | $203 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
Medium |
| X-Ray - Complete Intraoral Series | $165 | 0% | $165 |
Medium |
| X-Ray - Four Images, Bitewings | $81 | 0% | $81 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
Medium |
| X-Ray - Two Images, Bitewings | $64 | 0% | $64 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $146 | 0% | $146 |
Medium |
