| Dental Cleaning - Adult | $105 | 0% | $105 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $145 | 0% | $145 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $222 | 0% | $222 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $182 | 0% | $182 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | 0% | $168 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $321 | 0% | $321 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $563 | 0% | $563 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | 0% | $202 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $439 | 0% | $439 |
Medium |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
Medium |
| Fluoride - Topical Application | $49 | 0% | $49 |
Medium |
| Maintenance Therapy - Periodontal | $216 | 0% | $216 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $506 | 0% | $506 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| Root Canal - Anterior Tooth | $1,644 | 0% | $1,644 |
Medium |
| Root Canal - Bicuspid Tooth | $1,781 | 0% | $1,781 |
Medium |
| Root Canal - Molar | $2,207 | 0% | $2,207 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $183 | 0% | $183 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $237 | 0% | $237 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $129 | 0% | $129 |
Medium |
