| Dental Cleaning - Adult | $111 | 0% | $111 | 
Medium |
| Dental Cleaning - Child | $84 | 0% | $84 |
Medium |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $144 | 0% | $144 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $221 | 0% | $221 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $181 | 0% | $181 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $164 | 0% | $164 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $207 | 0% | $207 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $355 | 0% | $355 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $201 | 0% | $201 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | 0% | $273 |
Medium |
| Flouride - Topical Varnish Application | $55 | 0% | $55 |
Medium |
| Fluoride - Topical Application | $44 | 0% | $44 |
Medium |
| Maintenance Therapy - Periodontal | $153 | 0% | $153 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $278 | 0% | $278 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| Root Canal - Anterior Tooth | $852 | 0% | $852 |
Medium |
| Root Canal - Bicuspid Tooth | $965 | 0% | $965 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
Medium |
| X-Ray - Complete Intraoral Series | $145 | 0% | $145 |
Medium |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $54 | 0% | $54 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $142 | 0% | $142 |
Medium |
