| Dental Cleaning - Adult | $128 | 0% | $128 | 
Medium |
| Dental Cleaning - Child | $108 | 0% | $108 |
Medium |
| Dental Exam - Comprehensive | $103 | 0% | $103 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $244 | 0% | $244 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $369 | 0% | $369 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $308 | 0% | $308 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $217 | 0% | $217 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $238 | 0% | $238 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $369 | 0% | $369 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $278 | 0% | $278 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $314 | 0% | $314 |
Medium |
| Fluoride - Topical Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $174 | 0% | $174 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $301 | 0% | $301 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | 0% | $103 |
Medium |
| Root Canal - Anterior Tooth | $1,037 | 0% | $1,037 |
Medium |
| Root Canal - Bicuspid Tooth | $1,256 | 0% | $1,256 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | 0% | $68 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $227 | 0% | $227 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $42 | 0% | $42 |
Medium |
| X-Ray - Complete Intraoral Series | $184 | 0% | $184 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | 0% | $44 |
Medium |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $158 | 0% | $158 |
Medium |
