| Dental Cleaning - Adult | $95 | 0% | $95 | 
Medium |
| Dental Cleaning - Child | $75 | 0% | $75 |
Medium |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
Medium |
| Dental Exam - Periodic, Established Patient | $44 | 0% | $44 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $179 | 0% | $179 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $210 | 0% | $210 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $228 | 0% | $228 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $152 | 0% | $152 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $168 | 0% | $168 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $286 | 0% | $286 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $185 | 0% | $185 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $232 | 0% | $232 |
Medium |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
Medium |
| Fluoride - Topical Application | $42 | 0% | $42 |
Medium |
| Maintenance Therapy - Periodontal | $128 | 0% | $128 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $250 | 0% | $250 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | 0% | $79 |
Medium |
| Root Canal - Anterior Tooth | $788 | 0% | $788 |
Medium |
| Root Canal - Bicuspid Tooth | $1,680 | 0% | $1,680 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $53 | 0% | $53 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $179 | 0% | $179 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | 0% | $25 |
Medium |
| X-Ray - Complete Intraoral Series | $132 | 0% | $132 |
Medium |
| X-Ray - Four Images, Bitewings | $64 | 0% | $64 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $30 | 0% | $30 |
Medium |
| X-Ray - Two Images, Bitewings | $47 | 0% | $47 |
Medium |
